Macrocyclic compounds as ROS1 kinase inhibitors

ABSTRACT

Methods for inhibiting a ROS1 kinase with compounds of Formula I: 
                         
and pharmaceutically acceptable salts thereof, wherein ring A, ring B, W, m, D, R 2 , R 2a , R 3 , R 3a , and Z are as defined herein. The compounds and methods provided herein are useful in the treatment of cancer (e.g., ROS1-associated cancers as defined herein).

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of International Application No. PCT/US2018/022833, filed Mar. 16, 2018, which claims priority to U.S. Provisional Application No. 62/472,185, filed Mar. 16, 2017, the contents of which are incorporated by reference in their entirety herein.

TECHNICAL FIELD

Provided herein are compounds and pharmaceutical compositions comprising the compounds and the use of the compounds in therapy. More particularly, provided herein are certain macrocyclic compounds which exhibit ROS1 protein kinase inhibition, and which are useful in the treatment of cancer.

BACKGROUND

ROS1 is a receptor tyrosine kinase that is closely related to ALK, and, like ALK, it undergoes genomic rearrangement that creates fusion proteins in various cancers (Davies K D and Doebele R C (2013) Clin Cancer Res 19: 4040-4045). It is well established that these fusion proteins act as oncogenic drivers and that ROS1 inhibition is anti-proliferative in cells that express ROS1 fusions (Davies K D, Le A T, Theodoro M F, Skokan M C, Aisner D L, et al. (2012) Clin Cancer Res 18: 4570-4579). Thus, it appears that ROS1 targeted therapy will likely soon be the standard of care for this patient population. However, based on the experiences with other kinase inhibitors in various cancers, it is fully expected that acquired resistance to ROS1 inhibition will occur, and this will ultimately limit the treatment options for patients.

SUMMARY

It has now been found that macrocyclic compounds are inhibitors of ROS1 kinase, and are useful for treating various cancers. Compounds which are inhibitors of ROS1 may be useful in the treatment of multiple types of cancer including cancers exhibiting resistance to ROS1 inhibition.

Accordingly, in one aspect of the present disclosure, the methods provided include administration of a ROS1 inhibitor, wherein the ROS1 inhibitor is a compound of Formula I

or a pharmaceutically acceptable salt or solvate thereof, wherein ring A, ring B, W, m, D, R², R^(2a), R³, R^(3a), and Z are as defined herein.

In some embodiments, a compound of Formula I has the general formula:

or a pharmaceutically acceptable salt or solvate thereof, wherein ring A, W, m, R², R^(2a), R³, and Z are as defined herein.

In some embodiments, the compound of Formula I is selected from the compounds of Table 1, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the compound of Formula I is selected from the group consisting of Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof.

Provided herein is a method for treating a cancer in a patient in need thereof, the method comprising:

(a) determining if the cancer is associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same; and

(b) if the cancer is determined to be associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, administering to the patient a therapeutically effective amount of a ROS1 inhibitor, wherein the ROS1 inhibitor is a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof.

Provided herein is a method for treating a cancer in a patient in need thereof, the method comprising:

(a) detecting that the cancer is associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same; and

(b) administering to the patient a therapeutically effective amount of a ROS1 inhibitor, wherein the ROS1 inhibitor is a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof.

Also provided herein is a method for treating cancer in a patient in need thereof, the method comprising administering to a patient identified or diagnosed as having a ROS1-associated cancer a therapeutically effective amount of a ROS1 inhibitor, wherein the ROS1 inhibitor is a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof.

In some embodiments of the present disclosure, a method of treating cancer in a patient in need thereof is provided. The method comprising:

-   -   (a) determining if the cancer in a patient is a ROS1-associated         cancer; and     -   (b) administering to the patient determined to have a         ROS1-associated cancer a therapeutically effective amount of a         ROS1 inhibitor, wherein the ROS1 inhibitor is a compound of         Formula I or a pharmaceutically acceptable salt or solvate         thereof.

In some embodiments of the present disclosure, a method of treating cancer in a patient in need thereof is provided. The method comprising:

-   -   (a) detecting that a cancer in a patient is a ROS1-associated         cancer; and     -   (b) administering to the patient a therapeutically effective         amount of a ROS1 inhibitor, wherein the ROS1 inhibitor is a         compound of Formula I or a pharmaceutically acceptable salt or         solvate thereof.

Further provided herein is a method of treating a subject having a cancer, wherein the method comprises:

-   -   (a) administering a first ROS1 inhibitor to the subject;     -   (b) after (a), determining whether a cancer cell in a sample         obtained from the subject has one or more ROS1 inhibitor         resistance mutations; and     -   (c) administering a second ROS1 inhibitor, wherein the second         ROS1 inhibitor is a compound of Formula I or a pharmaceutically         acceptable salt or solvate thereof, as a monotherapy or in         conjunction with another anticancer agent to the subject if the         subject has a cancer cell that has one or more ROS1 inhibitor         resistance mutations; or     -   (d) administering additional doses of the first ROS1 inhibitor         of step (a) to the subject if the subject has a cancer cell that         does not have one or more ROS1 inhibitor resistance mutations.

Also provided herein is a method of treating a subject having a cancer, wherein the method comprises:

-   -   (a) administering a first ALK inhibitor to the subject;     -   (b) after (a), determining whether a cancer cell in a sample         obtained from the subject has one or more ROS1 inhibitor         resistance mutations; and     -   (c) administering a compound of Formula I, or a pharmaceutically         acceptable salt or solvate thereof, as a monotherapy or in         conjunction with another anticancer agent to the subject if the         subject has a cancer cell that has one or more ROS1 inhibitor         resistance mutations; or     -   (d) administering additional doses of the first ALK inhibitor of         step (a) to the subject if the subject has a cancer cell that         does not have one or more ROS1 inhibitor resistance mutations.

In some embodiments, a method of treating a subject having a cancer is provided herein, wherein the method comprises:

-   -   (a) administering a first TRK inhibitor to the subject;     -   (b) after (a), determining whether a cancer cell in a sample         obtained from the subject has one or more ROS1 inhibitor         resistance mutations; and     -   (c) administering a compound of Formula I, or a pharmaceutically         acceptable salt or solvate thereof, as a monotherapy or in         conjunction with another anticancer agent to the subject if the         subject has a cancer cell that has one or more ROS1 inhibitor         resistance mutations; or     -   (d) administering additional doses of the first TRK inhibitor of         step (a) to the subject if the subject has a cancer cell that         does not have one or more ROS1 inhibitor resistance mutations.

Also provided herein is a method of treating a subject having a cancer, wherein the method comprises:

-   -   (a) determining whether a cancer cell in a sample obtained from         a subject having a cancer and previously administered a first         ROS1 inhibitor has one or more ROS1 inhibitor resistance         mutations that confer increased resistance to a cancer cell or         tumor to treatment with the first ROS1 inhibitor that was         previously administered to the subject; and     -   (b) administering a compound of Formula I, or a pharmaceutically         acceptable salt or solvate thereof, as a monotherapy or in         conjunction with another anticancer agent to the subject if the         subject has a cancer cell that has one or more ROS1 inhibitor         resistance mutations that confers increased resistance to a         cancer cell or tumor to treatment with the first ROS1 inhibitor         that was previously administered to the subject; or     -   (c) administering additional doses of the first ROS1 inhibitor         to the subject if the subject has a cancer cell that does not         have one or more ROS1 inhibitor resistance mutations that         confers increased resistance to a cancer cell or tumor to         treatment with the first ROS1 inhibitor previously administered         to the subject.

Further provided herein is a method of treating a subject having a cancer, wherein the method comprises:

-   -   (a) determining whether a cancer cell in a sample obtained from         a subject having a cancer and previously administered a first         ALK inhibitor has one or more ROS1 inhibitor resistance         mutations; and     -   (b) administering a compound of Formula I, or a pharmaceutically         acceptable salt or solvate thereof, as a monotherapy or in         conjunction with another anticancer agent to the subject if the         subject has a cancer cell that has one or more ROS1 inhibitor         resistance mutations; or     -   (c) administering additional doses of the first ALK inhibitor to         the subject if the subject has a cancer cell that does not have         one or more ROS1 inhibitor resistance mutations.

In some embodiments, a method of treating a subject having a cancer is provided herein, wherein the method comprises:

-   -   (a) determining whether a cancer cell in a sample obtained from         a subject having a cancer and previously administered a first         TRK inhibitor has one or more ROS1 inhibitor resistance         mutations; and     -   (b) administering a compound of Formula I, or a pharmaceutically         acceptable salt or solvate thereof, as a monotherapy or in         conjunction with another anticancer agent to the subject if the         subject has a cancer cell that has one or more ROS1 inhibitor         resistance mutations; or     -   (c) administering additional doses of the first TRK inhibitor to         the subject if the subject has a cancer cell that does not have         one or more ROS1 inhibitor resistance mutations.

Also provided herein is a method of treating a subject having a cancer, wherein the method comprises:

-   -   (a) determining whether a cancer cell in a sample obtained from         a subject having a cancer and previously administered a first         ROS1 inhibitor has one or more ROS1 inhibitor resistance         mutations that confer increased resistance to a cancer cell or         tumor to treatment with the first ROS1 inhibitor previously         administered to the subject; and     -   (b) administering a second ROS1 inhibitor to the subject as a         monotherapy or in conjunction with another anticancer agent to         the subject if the subject has a cancer cell that has one or         more ROS1 inhibitor resistance mutations that confers increased         resistance to a cancer cell or tumor to treatment with the first         ROS1 inhibitor that was previously administered to the subject;         or     -   (c) administering additional doses of the first ROS1 inhibitor         that was previously administered to the subject if the subject         has a cancer cell that does not have one or more ROS1 inhibitor         resistance mutations that confers increased resistance to a         cancer cell or tumor to treatment with the first ROS1 inhibitor         that was previously administered to the subject.

Further provided herein is a method of treating a subject having a cancer, wherein the method comprises:

-   -   (a) determining whether a cancer cell in a sample obtained from         a subject having a cancer and previously administered an ALK         inhibitor has one or more ROS1 inhibitor resistance mutations;         and     -   (b) administering a ROS1 inhibitor to the subject as a         monotherapy or in conjunction with another anticancer agent to         the subject if the subject has a cancer cell that has one or         more ROS1 inhibitor resistance mutations; or     -   (c) administering additional doses of the ALK inhibitor that was         previously administered to the subject if the subject has a         cancer cell that does not have one or more ROS1 inhibitor         resistance mutations.

In some embodiments, a method of treating a subject having a cancer is provided, wherein the method comprises:

-   -   (a) determining whether a cancer cell in a sample obtained from         a subject having a cancer and previously administered a TRK         inhibitor has one or more ROS1 inhibitor resistance mutations;         and     -   (b) administering a ROS1 inhibitor to the subject as a         monotherapy or in conjunction with another anticancer agent to         the subject if the subject has a cancer cell that has one or         more ROS1 inhibitor resistance mutations; or     -   (c) administering additional doses of the TRK inhibitor that was         previously administered to the subject if the subject has a         cancer cell that does not have one or more ROS1 inhibitor         resistance mutations.

Also provided herein is a method of treating a patient, the method comprising administering a therapeutically effective amount of a compound of Formula I, or a pharmaceutically acceptable salt or solvate thereof, to a patient having a clinical record that indicates that the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same.

Further provided herein is a method of selecting a treatment for a patient, the method comprising selecting a treatment comprising administration of a compound of Formula I, or a pharmaceutically acceptable salt or solvate thereof, for a patient identified or diagnosed as having a ROS1-associated cancer.

In some embodiments, provided herein is a method of selecting a treatment for a patient having a cancer, the method comprising:

-   -   (a) determining if the cancer in the patient is a         ROS1-associated cancer; and     -   (b) selecting a treatment including administration of a         therapeutically effective amount of a compound of Formula I, or         a pharmaceutically acceptable salt or solvate thereof, for a         patient determined to have a ROS1-associated cancer.

Also provided herein is a method of selecting a patient for treatment including administration of a therapeutically effective amount of a compound of Formula I, or a pharmaceutically acceptable salt or solvate thereof, the method comprising:

-   -   (a) identifying a patient having a ROS1-associated cancer; and     -   (b) selecting the patient for treatment including administration         of a therapeutically effective amount of a compound of Formula         I, or a pharmaceutically acceptable salt or solvate thereof.

Further provided herein is a method of selecting a patient having cancer for treatment including administration of a therapeutically effective amount of a compound of Formula I, or a pharmaceutically acceptable salt or solvate thereof, the method comprising:

-   -   (a) determining if the cancer in the patient is a         ROS1-associated cancer; and     -   (b) selecting a patient determined to have a ROS1-associated         cancer for treatment including administration of a         therapeutically effective amount of a compound of Formula I, or         a pharmaceutically acceptable salt or solvate thereof.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Methods and materials are described herein for use in the present invention; other, suitable methods and materials known in the art can also be used. The materials, methods, and examples are illustrative only and not intended to be limiting. All publications, patent applications, patents, sequences, database entries, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control.

Other features and advantages of the invention will be apparent from the following detailed description and figures, and from the claims.

DETAILED DESCRIPTION

Provided herein are methods for using compounds of the general Formula I containing a pyrazolo[1,5-a]pyrimidinyl ring and having the structure:

or pharmaceutically acceptable salts or solvates thereof, wherein:

ring A is selected from rings A-1, A-2 and A-3 having the structures:

wherein the wavy line labeled 1 indicates the point of attachment of ring A to ring B and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R¹ is H, (1-3C)alkoxy or halogen;

ring B is selected from rings B-1 and B-2 having the structures:

wherein the wavy line labeled 3 indicates the point of attachment to ring A and the wavy line labeled 4 indicates the point of attachment to the pyrazolo[1,5-a]pyrimidine ring of Formula I;

W is O, NH or CH₂, wherein when ring A is A-2, then W is CH₂;

m is 0, 1 or 2;

D is carbon;

R² and R^(2a) are independently H, F, (1-3C)alkyl or OH, provided that R² and R^(2a) are not both OH;

R³ and R^(3a) are independently H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

or D is carbon or nitrogen, R² and R³ are absent and R^(2a) and R^(3a) together with the atoms to which they are attached form a 5-6 membered heteroaryl ring having 1-2 ring heteroatoms;

Z is *-NR^(4a)C(═O)—, *-ONHC(═O)—, *-NR^(4b)CH₂— or *-OC(═O)—, wherein the asterisk indicates the point of attachment of Z to the carbon bearing R³;

R^(4a) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl) or dihydroxy(2-6C alkyl);

R^(4b) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl), dihydroxy(2-6C alkyl), (1-6C alkyl)C(O)—, (3-6C cycloalkyl)C(O)—, Ar¹C(O)—, HOCH₂C(O)—, (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, Ar²(SO₂)—, HO₂CCH₂— or (1-6C alkyl)NH(CO)—;

Ar¹ is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy;

Ar² is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy; and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments of Formula I, ring B is ring B-2 having the structure:

D is carbon, R² and R^(2a) are independently (1-3C)alkyl, and R³ and R^(3a) are independently H, (1-3C)alkyl or hydroxy(1-3C)alkyl, or

D is carbon or nitrogen, R² and R³ are absent and R^(2a) and R^(3a) together with the atoms to which they are attached form a 5-6 membered heteroaryl ring having 1-2 ring heteroatoms.

In some embodiments of Formula I, ring A is ring A-1 having the structure

wherein X, Y and R¹ are as defined for Formula I. In some embodiments of Formula I, X is CH. In some embodiments, X is N. In some embodiments of Formula I, Y is F. In some embodiments, Y is H. In some embodiments of Formula I, R¹ is H. In some embodiments, R¹ is (1-3C)alkoxy. A particular example is methoxy. In some embodiments, R¹ is halogen. In some embodiments, R¹ is F.

Particular examples of ring A when represented by structure A-1 include the structures:

In some embodiments, ring A is ring A-2 having the structure

wherein Y is H or F. In some embodiments, Y is F. In some embodiments, Y is H. In some embodiments, R¹ is H. In some embodiments, R¹ is (1-3C)alkoxy. A particular example is methoxy. In some embodiments, R¹ is halogen. In some embodiments, R¹ is F.

Particular examples of ring A when represented by ring A-2 are the structures:

In some embodiments of Formula I, ring A is ring A-3 having the structure

wherein Y and R¹ is as defined for Formula I. In some embodiments, Y is F. In some embodiments, Y is H. In some embodiments, R¹ is H. In some embodiments, R¹ is (1-3C)alkoxy. A particular example is methoxy. In some embodiments, R¹ is halogen. In some embodiments, R¹ is F.

Particular examples of ring A when represented by ring A-3 are the structures:

In some embodiments of Formula I, W is O.

In some embodiments, W is NH.

In some embodiments, W is CH₂.

In some embodiments of Formula I, D is carbon, R² and R^(2a) are independently H, F, (1-3C)alkyl or OH (provided that R² and R^(2a) are not both OH), and R³ and R^(3a) are independently H, (1-3C)alkyl or hydroxy(1-3C)alkyl.

In some embodiments, R² and R^(2a) are independently H, F, methyl or OH, provided that R² and R^(2a) are not both OH.

In some embodiments, R² and R^(2a) are both H.

In some embodiments, R² is H and R^(2a) is F.

In some embodiments, R² and R^(2a) are both F.

In some embodiments, R² is H and R^(2a) is OH.

In some embodiments, R² is H and R^(2a) is methyl.

In some embodiments, R² and R^(2a) are both methyl.

In some embodiments, R³ and R^(3a) are independently H, (1-3C)alkyl or hydroxy(1-3 C)alkyl.

In some embodiments, R^(3a) is H. In some embodiments, R³ is H. In some embodiments, both R³ and R^(3a) are H.

In some embodiments, R^(3a) is (1-3C)alkyl. Examples include methyl, ethyl, propyl and isopropyl. In some embodiments, R³ is (1-3C)alkyl. Examples include methyl, ethyl, propyl and isopropyl.

In some embodiments, R^(3a) is (1-3C)alkyl and R³ is H. In some embodiments, R^(3a) is methyl and R³ is H.

In some embodiments, both R^(3a) and R³ are (1-3C)alkyl. In some embodiments, R^(3a) and R^(3a) are both methyl.

In some embodiments, R³ is hydroxy(1-3C)alkyl. Examples include hydroxymethyl, 2-hydroxyethyl, 2-hydroxypropyl, and 3-hydroxypropyl. In some embodiments, R³ is hydroxymethyl, 2-hydroxyethyl, 2-hydroxypropyl, or 3-hydroxypropyl and R^(3a) is H.

In some embodiments of Formula I, D is carbon or nitrogen, R² and R³ are absent, and R^(2a) and R^(3a) together with the atoms to which they are attached form a 5-6 membered heteroaryl ring having 1-2 ring heteroatoms. In some embodiments, R^(2a) and R^(3a) together with the atoms to which they are attached form a 5-6 membered heteroaryl ring having 1-2 ring nitrogen atoms. Examples of heteroaryl rings include pyridyl and pyrazolyl rings. Specific examples of heteroaryl rings include the structures:

In some embodiments, Z is *-NR^(4a)C(═O)—.

In some embodiments, R^(4a) is H.

In some embodiments, R^(4a) is (1-6C)alkyl. Examples include methyl, ethyl, propyl, isopropyl, butyl, and isobutyl.

In some embodiments, R^(4a) is fluoro(1-6C)alkyl. Examples include fluoromethyl and 2-fluoroethyl.

In some embodiments, R^(4a) is difluoro(1-6C)alkyl. Example include difluoromethyl and 2,2-difluoroethyl.

In some embodiments, R^(4a) is trifluoro(1-6C)alkyl. Examples include trifluoromethyl and 2,2,2-trifluoroethyl.

In some embodiments, R^(4a) is hydroxy(1-6C alkyl). Examples include hydroxymethyl, 2-hydroxyethyl, 2-hydroxypropyl and 3-hydroxypropyl.

In some embodiments, R^(4a) is dihydroxy(2-6C alkyl). An example includes 2,3-dihydroxypropyl.

In some embodiments, R^(4a) is H or (1-6C)alkyl. In some embodiments, R^(4a) is H or Me.

An example of Z when represented by *-NR^(4a)C(═O)— is *-ONHC(═O)—.

In some embodiments, Z is *-NR^(4b)CH₂—.

In some embodiments, R^(4b) is H.

In some embodiments, R^(4b) is selected from (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, and trifluoro(1-6C)alkyl.

In some embodiments, R^(4b) is (1-6C)alkyl. Examples include methyl, ethyl, propyl, isopropyl, butyl and tert-butyl. In some embodiments, R^(4b) is methyl.

In some embodiments, R^(4b) is fluoro(1-6C)alkyl. Examples include fluoromethyl and 2-fluoroethyl.

In some embodiments, R^(4b) is difluoro(1-6C)alkyl. Example include difluoromethyl and 2,2-difluoroethyl.

In some embodiments, R^(4b) is trifluoro(1-6C)alkyl. Examples include trifluoromethyl and 2,2,2-trifluoroethyl.

In some embodiments, R^(4b) is selected from (1-6C alkyl)C(O)—, (3-6C cycloalkyl)C(O)—, Ar¹C(O)— and HOCH₂C(O)—.

In some embodiments, R^(4b) is (1-6C alkyl)C(O)—. Examples include CH₃C(O)—, CH₃CH₂C(O)—, CH₃CH₂CH₂C(O)—, and (CH₃)₂CHC(O)—. In some embodiments, R⁴ is CH₃C(O)—.

In some embodiments, R^(4b) is (3-6C cycloalkyl)C(O)—. Examples include cyclopropylC(O)—, cyclobutylC(O)—, cyclopentylC(O)— and cyclohexylC(O)—.

In some embodiments, R^(4b) is Ar¹C(O)—. An example is phenylC(O)—.

In some embodiments, R^(4b) is HOCH₂C(O)—.

In some embodiments, R^(4b) is selected from (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, and Ar²(SO₂)—.

In some embodiments, R^(4b) is (1-6C alkyl)sulfonyl. Examples include methyl sulfonyl, ethyl sulfonyl and propyl sulfonyl.

In some embodiments, R^(4b) is (3-6C cycloalkyl)sulfonyl. Examples include cyclopropylsulfonyl, cyclobutylsulfonyl, cyclopentylsulfonyl and cyclohexylsulfonyl. In some embodiments, R⁴ is methylsulfonyl.

In some embodiments, R^(4b) is Ar²(SO₂)—. An example is phenylsulfonyl.

In some embodiments, R^(4b) is HO₂CCH₂—.

In some embodiments, R^(4b) is (1-6C alkyl)NH(CO)—. Examples include CH₃NHC(O)—, CH₃CH₂NHC(O)—, CH₃CH₂CH₂NHC(O)—, and (CH₃)₂CHNHC(O)—. In some embodiments, R⁴ is CH₃NHC(O)—.

In some embodiments, R^(4b) is selected from H, methyl, —C(O)CH₃, methylsulfonyl, —C(O)CH₂OH, —CH₂COOH and —C(O)NHCH₂CH₃.

In some embodiments, Z is *-OC(═O)—.

In some embodiments of Formula I, ring B is ring B-1:

where R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments, R⁵ and R⁶ are independently H, F, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl. In some embodiments, R⁵ is H and R⁶ is H, F, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments, R⁵ and R⁶ are independently H, F, OH, (1-3C)alkyl or hydroxy(1-3C)alkyl. In some embodiments, R⁵ is hydrogen and R⁶ is H, F, OH, (1-3C)alkyl or hydroxy(1-3C)alkyl.

In some embodiments, R⁵ and R⁶ are independently H, F, OH, methyl, ethyl, HOCH₂— or HOCH₂CH₂—. In some embodiments, R⁵ is hydrogen and R⁶ is H, F, OH, methyl, ethyl, HOCH₂— or HOCH₂CH₂—.

In some embodiments, R⁵ and R⁶ are independently H, F, or methyl. In some embodiments, R⁵ is H and R⁶ is H, F, or methyl.

In some embodiments, R⁵ is H and R⁶ is F.

In some embodiments, R⁵ is H and R⁶ is methyl.

In some embodiments, R⁵ and R⁶ are both H.

In some embodiments, R⁵ and R⁶ are both F.

In some embodiments, R⁵ and R⁶ are both methyl.

In some embodiments, ring B is ring B-1 which is optionally substituted with one or two substituents independently selected from OH and F, provided that two OH substituents are not on the same ring carbon atom.

Particular examples of ring B when represented by ring B-1 include the structures:

In some embodiments of Formula I, ring B is ring B-2 having the formula:

In some embodiments, m is 0.

In some embodiments, m is 1.

In some embodiments, m is 2.

Provided herein are compounds of the general Formula I or pharmaceutically acceptable salts or solvates thereof, wherein:

ring B is ring B-1:

ring A is selected from rings A-1, A-2 and A-3 having the structures:

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R¹ is H, (1-3C)alkoxy or halogen;

W is O, NH or CH₂, wherein when ring A is A-2, then W is CH₂;

m is 0, 1 or 2;

D is carbon;

R² and R^(2a) are independently H, F, (1-3C)alkyl or OH, provided that R² and R^(2a) are not both OH;

R³ and R^(3a) are independently H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

or R² and R³ are absent and R^(2a) and R^(3a) together with the atoms to which they are attached form a bivalent 5-6 membered heteroaryl ring having 1-2 ring nitrogen atoms;

Z is *-NR^(4a)C(═O)—, *-ONHC(═O)—, *-NR^(4b)CH₂— or *-OC(═O)—, wherein the asterisk indicates the point of attachment of Z to the carbon bearing R³;

R^(4a) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl) or dihydroxy(2-6C alkyl);

R^(4b) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl), dihydroxy(2-6C alkyl), (1-6C alkyl)C(O)—, (3-6C cycloalkyl)C(O)—, Ar¹C(O)—, HOCH₂C(O)—, (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, Ar²(SO₂)—, HO₂CCH₂— or (1-6C alkyl)NH(CO)—;

Ar¹ is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy;

Ar² is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy; and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

Also provided herein are compounds of the general Formula IA

or pharmaceutically acceptable salts or solvates thereof, wherein:

ring A is selected from rings A-1, A-2 and A-3 having the structures:

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R¹ is H, (1-3C)alkoxy or halogen;

W is O, NH or CH₂, wherein when ring A is A-2, then W is CH₂;

m is 0, 1 or 2;

R² and R^(2a) are independently H, F, or OH, provided that R² and R^(2a) are not both OH;

R³ is H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, *-ONHC(═O)—, *-NR^(4b)CH₂— or *-OC(═O)—, wherein the asterisk indicates the point of attachment of Z to the carbon bearing R³;

R^(4a) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl) or dihydroxy(2-6C alkyl);

R^(4b) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl), dihydroxy(2-6C alkyl), (1-6C alkyl)C(O)—, (3-6C cycloalkyl)C(O)—, Ar¹C(O)—, HOCH₂C(O)—, (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, Ar²(SO₂)—, HO₂CCH₂— or (1-6C alkyl)NH(CO)—;

Ar¹ is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy;

Ar² is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy; and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-1 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R¹ is H, (1-3C)alkyl, (1-3C)alkoxy or halogen;

W is O or NH;

m is 0, 1 or 2;

R² and R^(2a) are independently H, F, or OH, provided that R² and R^(2a) are not both OH;

R³ is H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, *-ONHC(═O)—, or *-OC(═O)—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4a) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl) or dihydroxy(2-6C alkyl); and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments of Formula IA, X is N. In some embodiments, X is CH.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-2 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

Y is H or F;

R¹ is H, (1-3C)alkyl, (1-3C)alkoxy or halogen;

m is 0, 1 or 2;

W is CH₂;

m is 0, 1 or 2;

R² and R^(2a) are independently H, F, or OH, provided that R² and R^(2a) are not both OH;

R³ is H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4a) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl) or dihydroxy(2-6C alkyl); and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-3 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

Y is H or F;

R¹ is H, (1-3C)alkyl, (1-3C)alkoxy or halogen;

W is O;

m is 0, 1 or 2;

R² and R^(2a) are independently H, F, or OH, provided that R² and R^(2a) are not both OH;

R³ is H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

Z is *-OC(═O)— or *-NR^(4a)C(═O)—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4a) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl, hydroxy(1-6C alkyl) or dihydroxy(2-6C alkyl); and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-1 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R³ is H, (1-3C)alkyl, (1-3C)alkoxy or halogen;

W is O;

m is 0, 1 or 2;

R² and R^(2a) are independently H, F, or OH, provided that R² and R^(2a) are not both OH;

R³ is H, (1-3C)alkyl or hydroxy(1-3C)alkyl;

Z is *-NR^(4b)CH₂—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4b) is H, (1-6C)alkyl, fluoro(1-6C)alkyl, difluoro(1-6C)alkyl, trifluoro(1-6C)alkyl (1-6C alkyl)C(O)—, (3-6C cycloalkyl)C(O)—, Ar¹C(O)—, HOCH₂C(O)—, (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, Ar²(SO₂)—, HO₂CCH₂— or (1-6C alkyl)NH(CO)—;

Ar¹ is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy;

Ar² is phenyl optionally substituted with one or more substituents independently selected from halogen, (1-6C)alkyl, and (1-6C)alkoxy; and

R⁵ and R⁶ are independently H, halogen, OH, (1-6C)alkyl or hydroxy(1-6C)alkyl.

In some embodiments of general Formula IA,

ring A is selected from rings A-1, A-2 and A-3 having the structures:

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R¹ is H;

W is O or CH₂, wherein when ring A is A-2, then W is CH₂;

m is 0 or 1;

R² and R^(2a) are independently H, F, (1-3C)alkyl, or OH, provided that R² and R^(2a) are not both OH;

R³ is H or (1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, *-NR^(4b)CH₂— or *-OC(═O)—, wherein the asterisk indicates the point of attachment of Z to the carbon bearing R³;

R^(4a) is H;

R^(4b) is (1-6C alkyl)C(O)—; and

R⁵ and R⁶ are independently H or halogen.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-1 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

X is N or CH;

Y is H or F;

R¹ is H;

W is O or CH₂;

m is 0 or 1;

R² and R^(2a) are independently H, F, (1-3C)alkyl, or OH, provided that R² and R^(2a) are not both OH;

R³ is H or (1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4a) is H; and

R⁵ and R⁶ are independently H or halogen.

In some embodiments of Formula IA where ring A is ring A-1, X is N. In some such embodiments of Formula IA where ring A is ring A-1, W is O. In some embodiments of Formula IA where ring A is ring A-1, W is CH₂. In some embodiments of Formula IA where ring A is ring A-1, R² and R^(2a) are H. In some embodiments of Formula IA where ring A is ring A-1, R² and R^(2a) are independently F, (1-3C)alkyl, or OH. In some embodiments of Formula IA where ring A is ring A-1, R³ is (1-3C)alkyl. In some embodiments of Formula IA where ring A is ring A-1, R³ is H. In some embodiments of Formula IA where ring A is ring A-1, Z is *-NR^(4a)C(═O)—. In some embodiments of Formula IA where ring A is ring A-1, R⁵ and R⁶ are H.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-2 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

Y is H or F;

R¹ is H;

W is CH₂;

m is 0 or 1;

R² and R^(2a) are independently H, F, (1-3C)alkyl, or OH, provided that R² and R^(2a) are not both OH;

R³ is H or (1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4a) is H; and

R⁵ and R⁶ are independently H or halogen.

In some embodiments of Formula IA where ring A is ring A-2, Y is F. In some embodiments of Formula IA where ring A is ring A-2, R² and R^(2a) are H. In some embodiments of Formula IA where ring A is ring A-2, R² and R^(2a) are independently H or (1-3C)alkyl. In some embodiments of Formula IA where ring A is ring A-2, R³ is (1-3 C)alkyl. In some embodiments of Formula IA where ring A is ring A-2, R³ is H. In some embodiments of Formula IA where ring A is ring A-2, R⁵ and R⁶ are H.

In some embodiments, Formula IA includes compounds wherein:

ring A is ring A-3 represented by the structure

wherein the wavy line labeled 1 indicates the point of attachment of ring A to the pyrrolidine ring of Formula I and the wavy line labeled 2 indicates the point of attachment of ring A to W;

Y is H or F;

R¹ is H;

W is O;

m is 0 or 1;

R² and R^(2a) are independently H, F, (1-3C)alkyl, or OH, provided that R² and R^(2a) are not both OH;

R³ is H or (1-3C)alkyl;

Z is *-NR^(4a)C(═O)—, wherein the asterisk indicates the point of attachment to the carbon bearing R³;

R^(4a) is H; and

R⁵ and R⁶ are independently H or halogen.

In some embodiments of Formula IA where ring A is ring A-3, Y is F. In some embodiments of Formula IA where ring A is ring A-3, Y is H. In some embodiments of Formula IA where ring A is ring A-3, R² and R^(2a) are H. In some embodiments of Formula IA where ring A is ring A-3, R² and R^(2a) are independently H or (1-3C)alkyl. In some embodiments of Formula IA where ring A is ring A-3, R³ is (1-3C)alkyl. In some embodiments of Formula IA where ring A is ring A-3, R³ is H. In some embodiments of Formula IA where ring A is ring A-3, R⁵ and R⁶ are H.

It will be appreciated that certain compounds as provided herein may contain one or more centers of asymmetry and may therefore be prepared and isolated as a mixture of isomers such as a racemic or diastereomeric mixture, or in an enantiomerically or diastereomerically pure form. It is intended that all stereoisomeric forms of the compounds provided herein, including but not limited to, diastereomers, enantiomers and atropisomers, as well as mixtures thereof such as racemic mixtures, form part of the present disclosure.

In some embodiments, compounds of the general Formula I wherein Ring B is ring B-1 have the absolute configuration of Formula 1-a:

In some embodiments, compounds of the general Formula I wherein Ring B is ring B-1 have the absolute configuration of Formula 1-b:

In the structures shown herein, where the stereochemistry of any particular chiral atom is not specified, then all stereoisomers are contemplated and included as the compounds of the disclosure. Where stereochemistry is specified by a solid wedge or dashed line representing a particular configuration, then that stereoisomer is so specified and defined.

The terms “(1-3C)alkyl” and “(1-6C)alkyl” as used herein refer to saturated linear or branched-chain monovalent hydrocarbon radicals of one to three carbon atoms and one to six carbon atoms, respectively. Examples include, but are not limited to, methyl, ethyl, 1-propyl, isopropyl, 1-butyl, isobutyl, sec-butyl, tert-butyl, 2-methyl-2-propyl, pentyl, and hexyl.

The term “fluoro(1-6C)alkyl” as used herein refers to saturated linear or branched-chain monovalent hydrocarbon radicals of one to six carbon atoms as defined herein, wherein one of the hydrogens is replaced by a fluorine atom.

The term “difluoro(1-6C)alkyl” as used herein refers to saturated linear or branched-chain monovalent hydrocarbon radicals of one to six carbon atoms as defined herein, wherein two of the hydrogens are replaced by fluorine atoms.

The term “trifluoro(1-6C)alkyl” as used herein refers to saturated linear or branched-chain monovalent hydrocarbon radicals of one to six carbon atoms as defined herein, wherein three of the hydrogens are replaced by fluorine atoms.

The term “hydroxy(1-6Calkyl) as used herein refers to saturated linear or branched-chain monovalent hydrocarbon radicals of one to six carbon atoms, wherein one of the hydrogens is replaced by a hydroxy (OH) group.

The term “dihydroxy(2-6C alkyl) as used herein refers to saturated linear or branched-chain monovalent hydrocarbon radicals of two to six carbon atoms as defined herein, wherein two of the hydrogens are replaced by hydroxy (OH) groups, provided the hydroxy groups are not on the same carbon atom.

The term “(1-6C alkyl)sulfonyl” as used herein refers to a (1-6C alkyl)SO₂— group, wherein the radical is on the sulfur atom and the (1-6C alkyl) portion is as defined above. Examples include methylsulfonyl (CH₃SO₂—) and ethylsulfonyl (CH₃CH₂SO₂—).

The term “(3-6C cycloalkyl)sulfonyl” as used herein refers to a (3-6C cycloalkyl)SO₂— group, wherein the radical is on the sulfur atom. An example is cyclopropylsulfonyl.

The terms “(1-3C)alkoxy” and “(1-6C)alkoxy”, as used herein refer to saturated linear or branched-chain monovalent alkoxy radicals of one to three carbon atoms or one to six carbon atoms, respectively, wherein the radical is on the oxygen atom. Examples include methoxy, ethoxy, propoxy, isopropoxy, and butoxy.

The term “halogen” includes fluoro, chloro, bromo and iodo.

Non-limiting examples of the compounds of Formula I include those in Table 1.

TABLE 1 Compound No. Compound Structure Compound Name  1

(6R)-9-fluoro-2,11,15,19,20,23- hexaazapentacyclo[15.5.2.1^(7,11).0^(2,6).0^(20,24)] pentacosa-1(23),7,9,17(24),18,21- hexaene-16,25-dione  2

(6R)-12-oxa-2,16,20,21,24,26- hexaazapentacyclo[16.5.2.1^(7,11).0^(2,6).0^(21,25)] hexacosa-1(24),7(26),8,10,18(25),19,22- heptaen-17-one  3

(6R)-9-fluoro-13-oxa-2,11,17,21,22,25- hexaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one  4

(6R)-9-fluoro-15-hydroxy-13-oxa- 2,11,17,21,22,25- hexaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one  5

(6R,13S)-9-fluoro-13-hydroxy- 2,11,15,19,20,23-hexaazapentacyclo- [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione  5-B

(6R,13R)-9-fluoro-13-hydroxy- 2,11,15,19,20,23-hexaazapentacyclo- [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione  6

(6R)-9-fluoro-15-hydroxy-13-oxa- 2,11,17,21,22,25-hexaazapentacyclo- [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7,9,11,19(26),20,23-heptaen-18- one  7

(6R,15R)-9-fluoro-15-hydroxy-13-oxa- 2,11,17,21,22,25-hexaazapentacyclo- [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7,9,11,19(26),20,23-heptaen-18- one  7-B

(6R,15S)-9-fluoro-15-hydroxy-13-oxa- 2,11,17,21,22,25-hexaazapentacyclo- [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7,9,11,19(26),20,23-heptaen-18- one  8

(6R,13R)-9-fluoro-13-hydroxy- 2,11,15,19,20,23-hexaazapentacyclo- [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione  8-B

(6R,13S)-9-fluoro-13-hydroxy- 2,11,15,19,20,23-hexaazapentacyclo- [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione  9

(6R)-9-fluoro-13-oxa-2,11,16,20,21,24- hexaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 10

(6R)-9-fluoro-13-oxa-2,11,18,22,23,26- hexaazapentacyclo[18.5.2.0^(2,6).0^(7,12).0^(23,27)] heptacosa-1(26),7,9,11,20(27),21,24- heptaen-19-one 11

(6R)-9-fluoro-2,11,16,20,21,24- hexaazapentacyclo[16.5.2.1^(7,11).0^(2,6).0^(21,25)] hexacosa-1(24),7,9,18(25),19,22- hexaene-17,26-dione 12

(6R)-9-fluoro-2,11,13,16,20,21,24- heptaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 13

(6R)-9-fluoro-2,11,13,17,21,22,25- heptaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one 14

(6R)-9-fluoro-13,16-dioxa-2,11,20,21,24- pentaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)]- pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 15

(6R)-9-fluoro-14-oxa-2,11,18,19,22- pentaazapentacyclo[14.5.2.1^(7,11).0^(2,6).0^(19,23)] tetracosa-1(22),7,9,16(23),17,20- hexaene-15,24-dione 16

(6R)-9-fluoro-13,16-dioxa- 2,11,17,21,22,25- hexaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one 17

(6R,13R)-9,13-difluoro-2,11,15,19,20,23- hexaazapentacyclo[15.5.2.1^(7,11).0^(2,6).0^(20,24)] pentacosa-1(23),7,9,17(24),18,21- hexaene-16,25-dione 17-B

(6R,13S)-9,13-difluoro-2,11,15,19,20,23- hexaazapentacyclo[15.5.2.1^(7,11).0^(2,6).0^(20,24)] pentacosa-1(23),7,9,17(24),18,21- hexaene-16,25-dione 18

(6R)-9-fluoro-17-methyl-13-oxa- 2,11,17,21,22,25- hexaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one 19

(6R)-9,15,15-trifluoro-13-oxa- 2,11,17,21,22,25- hexaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one 20

(6R)-9-fluoro-13-oxa-2,17,21,22,25- pentaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaen-18-one 21

(6R)-9-fluoro-13-oxa-2,16,20,21,24- pentaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaene 22

1-[(6R)-9-fluoro-13-oxa-2,16,20,21,24- pentaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-16-yl]ethan-1-one 23

1-[(6R)-9-fluoro-13-oxa-2,16,20,21,24- pentaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-16-yl]-2-hydroxyethan-1-one 24

(6R)-9-fluoro-13-oxa-2,17,21,22,25- pentaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaene 25

(6R)-9-fluoro-16-methanesulfonyl-13- oxa-2,16,20,21,24- pentaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaene 26

2-[(6R)-9-fluoro-13-oxa-2,16,20,21,24- pentaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-16-yl]acetic acid 27

(6R)-9-fluoro-17-methanesulfonyl-13- oxa-2,17,21,22,25- pentaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7,9,11,19(26),20,23- heptaene 28

(6R)-N-ethyl-9-fluoro-13-oxa- 2,17,21,22,25-pentaazapentacyclo 17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7,9,11,19(26),20,23-heptaene-17- carboxamide 29

(6R)-N-ethyl-9-fluoro-13-oxa- 2,16,20,21,24-pentaazapentacyclo- [16.5.2.0^(2,6).0^(7,12).0^(21,25)]pentacosa- 1(24),7,9,11,18(25),19,22-heptaene-16- carboxamide 30

(6S)-9-fluoro-4,13-dioxa- 2,11,17,21,22,25-hexaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaene- 3,18-dione 31

(6S)-9-fluoro-4,13-dioxa- 2,11,16,20,21,24-hexaazapentacyclo [16.5.2.0^(2,6).0^(7,12).0^(21,25)]pentacosa- 1(24),7(12),8,10,18(25),19,22-heptaene- 3,17-dione 32

(6R)-9-fluoro-2,11,16,20,21,24- hexaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 33

(6R)-9-fluoro-15-methyl- 2,11,16,20,21,24- hexaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 33-A

(6R,15S)-9-fluoro-15-methyl- 2,11,16,20,21,24- hexaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 33-B

(6R,15R)-9-fluoro-15-methyl- 2,11,16,20,21,24- hexaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)] pentacosa-1(24),7,9,11,18(25),19,22- heptaen-17-one 34

(6R,13R)-9-fluoro-13-methyl- 2,11,15,19,20,23-hexaazapentacyclo [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione 35

(6R,13S)-9-fluoro-13-methyl- 2,11,15,19,20,23 -hexaazapentacyclo [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione 36

(6R)-9-fluoro-15,15-dimethyl-13-oxa- 2,11,17,21,22,25-hexaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7,9,11,19(26),20,23-heptaen-18- one 37

(6R)-9-fluoro-15,15-dimethyl- 2,11,16,20,21,24-hexaazapentacyclo [16.5.2.0^(2,6).0^(7,12).0^(21,25)]pentacosa- 1(24),7,9,11,18(25),19,22-heptaen-17- one 38

(6R)-9-fluoro-13-oxa- 2,11,16,17,21,25,26,29-octaazahexacyclo [21.5.2.0^(2,6).0^(7,12).0^(16,20).0^(26,30)]triaconta- 1(29),7,9,11,17,19,23(30),24,27-nonaen- 22-one 39

(6R)-9-fluoro-13-oxa- 2,11,19,21,25,26,29-heptaazahexacyclo [21.5.2.0^(2,6).0^(7,12).0^(15,20).0^(26,30)]triaconta- 1(29),7,9,11,15(20),16,18,23(30),24,27- decaen-22-one 40

(6R)-9-fluoro-13,13-dimethyl- 2,11,15,19,20,23-hexaazapentacyclo [15.5.2.1^(7,11).0^(2,6).0^(20,24)]pentacosa- 1(23),7,9,17(24),18,21-hexaene-16,25- dione 41

(4R,6R,15S)-9-fluoro-4,15-dihydroxy- 13-oxa-2,17,21,22,25- pentaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaen- 18-one 41-B

(4R,6S,15S)-9-fluoro-4,15-dihydroxy- 13-oxa-2,17,21,22,25- pentaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaen- 18-one 42

(4R,6R)-9-fluoro-4-hydroxy-13-oxa- 2,17,21,22,25-pentaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaen- 18-one 42-B

(4R,6S)-9-fluoro-4-hydroxy-13-oxa- 2,17,21,22,25-pentaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaen- 18-one 43

(4R,6R)-9-fluoro-4-hydroxy-13-oxa- 2,16,20,21,24-pentaazapentacyclo [16.5.2.0^(2,6).0^(7,12).0^(21,25)]pentacosa- 1(24),7,9,11,18(25),19,22-heptaen-17- one 43-B

(4R,6S)-9-fluoro-4-hydroxy-13-oxa- 2,16,20,21,24-pentaazapentacyclo [16.5.2.0^(2,6).0^(7,12).0^(21,25)]pentacosa- 1(24),7,9,11,18(25),19,22-heptaen-17- one 44

(4R,6R,15R)-9-fluoro-4,15-dihydroxy- 13-oxa-2,17,21,22,25- pentaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaen- 18-one 44-B

(4R,6S,15R)-9-fluoro-4,15-dihydroxy-13- oxa-2,17,21,22,25-pentaazapentacyclo [17.5.2.0^(2,6).0^(7,12).0^(22,26)]hexacosa- 1(25),7(12),8,10,19(26),20,23-heptaen- 18-one 45

Diastereomer 1 and Diastereomer 2 of (15S)-4,4,9-trifluoro-15-hydroxy-13-oxa- 2,17,21,22,25- pentaazapentacyclo[17.5.2.0^(2,6).0^(7,12).0^(22,26)] hexacosa-1(25),7(12),8,10,19(26),20,23- heptaen-18-one

It will also be appreciated that certain compounds of Formula I may be used as intermediates for the preparation of further compounds of Formula I.

The compounds of Formula I include salts thereof. In certain embodiments, the salts are pharmaceutically acceptable salts. In addition, the compounds of Formula I include other salts of such compounds which are not necessarily pharmaceutically acceptable salts, and which may be useful as intermediates for preparing and/or purifying compounds of Formula I and/or for separating enantiomers of compounds of Formula I.

The term “pharmaceutically acceptable” indicates that the substance or composition is compatible chemically and/or toxicologically, with the other ingredients comprising a formulation, and/or the mammal being treated therewith.

It will further be appreciated that the compounds of Formula I and their salts may be isolated in the form of solvates, and accordingly that any such solvate is included within the scope of the present disclosure.

The compounds provided herein may also contain unnatural proportions of atomic isotopes at one or more of the atoms that constitute such compounds. That is, an atom, in particular when mentioned in relation to a compound according to Formula I, comprises all isotopes and isotopic mixtures of that atom, either naturally occurring or synthetically produced, either with natural abundance or in an isotopically enriched form. For example, when hydrogen is mentioned, it is understood to refer to ¹H, ²H, ³H or mixtures thereof; when carbon is mentioned, it is understood to refer to ¹¹C, ¹²C, ¹³C, ¹⁴C or mixtures thereof; when nitrogen is mentioned, it is understood to refer to ¹³N, ¹⁴N, ¹⁵N or mixtures thereof; when oxygen is mentioned, it is understood to refer to ¹⁴O, ¹⁵O, ¹⁶O, ¹⁷O, ¹⁸O or mixtures thereof and when fluoro is mentioned, it is understood to refer to ¹⁸F, ¹⁹F or mixtures thereof. The compounds provided herein therefore also comprise compounds with one or more isotopes of one or more atom, and mixtures thereof, including radioactive compounds, wherein one or more non-radioactive atoms has been replaced by one of its radioactive enriched isotopes. Radiolabeled compounds are useful as therapeutic agents, e.g., cancer therapeutic agents, research reagents, e.g., assay reagents, and diagnostic agents, e.g., in vivo imaging agents. All isotopic variations of the compounds of the present disclosure, whether radioactive or not, are intended to be encompassed within the scope of the present disclosure.

The compounds of Formula I or a salt thereof as defined herein can be prepared as described in U.S. Pat. No. 8,933,084, which is incorporated by reference in its entirety herein. For example, a process for preparing a compound of Formula I or a salt thereof as defined herein can include:

(a) for a compound of Formula I wherein Z is *-NHC(═O)—, and ring A, ring B, W, D, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, cyclizing a corresponding compound having the formula II

where P¹ is H or a carboxyl protecting group, in the presence of a coupling reagent and a base; or

(b) for a compound of Formula I wherein W is O, ring A is formula A-1:

X is N, and ring B, D, Z, Y, R¹, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, cyclizing a corresponding compound having the formula III

where n is 1, 2, 3 or 4 and L¹ is a leaving group or atom, in the presence of a base; or

(c) for a compound of Formula I wherein W is CH₂, ring A is formula A-2:

and ring B, Z, D, Y, R¹, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, cyclizing a corresponding compound having the formula IV

where L² is a leaving group or atom, in the presence of a base; or

(d) for a compound of Formula I wherein Z is *-NHC(═O)—, and ring A, ring B, W, D, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, cyclizing a corresponding compound having the formula V

in the presence of a base and a coupling reagent; or

(e) for a compound of Formula I wherein Z is *-NHCH₂—, and ring A, ring B, W, D, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, cyclizing a corresponding compound having the formula VI

in the presence of a reducing agent; or

(f) for a compound of Formula I wherein Z is *-NHCH₂—, and ring A, ring B, W, D, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, cyclizing a corresponding compound having the formula VII

in the presence of triphenylphosphine; or

(g) for a compound of Formula I wherein ring A, ring B, W, D, m, R², R^(2a), R³, and R^(3a) are as defined for Formula I, Z is *-NR^(4b)CH₂—, and R^(4b) is (1-6C alkyl)C(O)—, (3-6C cycloalkyl)C(O)—, Ar¹C(O)—, HOCH₂C(O)—, (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, (1-6C alkyl)sulfonyl, (3-6C cycloalkyl)sulfonyl, or Ar²(SO₂)—, coupling a corresponding compound having the formula VIII

with a reagent having the formula (1-6C alkyl)C(O)-L³, (3-6C cycloalkyl)C(O)-L³, Ar¹C(O)-L³, HOCH₂C(O)-L³, (1-6C alkyl)(SO₂)-L³, (3-6C cycloalkyl)(SO₂)-L³, or Ar²(SO₂)-L³, respectively, where L³ is a leaving atom, in the presence of a base; or

(h) for a compound of Formula I wherein ring A, ring B, W, D, R², R^(2a), R³, R^(3a) and m are as defined for Formula I, Z is *-NR^(4b)CH₂—, and R^(4b) is (1-6C alkyl)NH(CO)—, reacting a compound having the formula VIII

with a reagent having the formula (1-6C alkyl)N═C═O in the presence of a base; or

(i) for a compound of Formula I wherein R² is F, R^(2a) is H, and ring A, ring B, Z, W, D, R³, R^(3a), and m are as defined for Formula I, reacting a corresponding compound having the formula IX

with a fluorination reagent;

(j) for a compound of Formula I wherein W is O, ring A is formula A-1,

X is CH, and Y, R¹, D, ring B, Z, R², R^(2a), R³ and m are as defined for Formula I, cyclizing a corresponding compound having the formula X

where n is 1, 2, 3 or 4 and L¹ is a leaving group or atom, in the presence of a base; and

optionally removing any protecting groups and optionally preparing a salt thereof.

In some embodiments of the above-described methods (a)-(j), ring B is ring B-1 having the structure:

D is carbon, R² and R^(2a) are independently H, F, (1-3C)alkyl or OH (provided that R² and R^(2a) are not both OH), R³ is H, (1-3C)alkyl or hydroxy(1-3C)alkyl, and ring A, W, m, Z, Y, R^(3a), R⁵ and R⁶ are as defined for Formula I.

Referring to method (a), the cyclization may be performed using conventional amide bond formation conditions, for example by treating the carboxylic acid with an activating agent, followed by addition of the amine in the presence of a base. Suitable activating agents include EDCI, oxalyl chloride, thionyl chloride, HATU, and HOBt. Suitable bases include amine bases, for example triethylamine, diisopropylethylamine, pyridine, or excess ammonia. Suitable solvents include DCM, DCE, THF and DMF.

Referring to methods (b) and (c), the leaving atoms L¹ and L² may be, for example a halogen atom such as Br, Cl or I. Alternatively, L¹ and L² can be a leaving group, for example an arylsulfonyloxy group or an alkylsulfonyloxy group, such as a mesylate or a tosylate group. Suitable bases include alkali metal carbonates, such as sodium carbonate, potassium carbonate or cesium carbonate. Convenient solvents include aprotic solvents such as ethers (for example tetrahydrofuran or p-dioxane), DMF, or acetone. The reaction can be conveniently performed at elevated temperatures, for example 50-150° C., for example at 85° C.

Referring to method (d), suitable coupling reagents include HATU, HBTU, TBTU, DCC, DIEC, and any other amide coupling reagents well known to persons skilled in the art. Suitable bases include tertiary amine bases such as DIEA and triethylamine. Convenient solvents include DMF, THF, DCM and DCE.

Referring to method (e), suitable reducing agents include Me₄N(OAc)₃BH, Na(OAc)₃BH and NaCNBH₃. Suitable solvents include neutral solvents such as acetonitrile, THF and DCE. The reaction can be conveniently performed at ambient temperature.

Referring to method (f), in certain embodiments the triphenylphosphine reagent is used in the form of a polystyrene-bound PPh₃ resin (sold as PS-PPh₃ by Biotage Systems). The reaction is conveniently performed at ambient temperature. Suitable solvents include neutral solvents, for example DCM.

Referring to method (g), the leaving atom L³ may be a halogen, for example Cl or Br. Suitable bases include tertiary amine bases such as diisopropylethylamine and triethylamine. The reaction is conveniently performed at ambient temperature.

Referring to method (h), suitable bases include tertiary amine bases such as DIEA and triethylamine. The reaction is conveniently performed at ambient temperature.

Referring to method (i), the fluorination reagent may be, for example, bis(2-methoxyethyl)amino-sulfur trifluoride (Deoxo-Fluor™) or diethylaminosulfur trifluoride (DAST). Suitable solvents include dichloromethane, chloroform, dichloroethane, and toluene. The reaction is conveniently performed at ambient temperature.

Referring to method (j), base may be, for example, an alkali metal carbonate, such as for example sodium carbonate, potassium carbonate or cesium carbonate. Convenient solvents include aprotic solvents such as ethers (for example tetrahydrofuran or p-dioxane) or toluene. The reaction can be conveniently performed at a temperature between ambient temperature and reflux, for example at 85° C.

Amine groups in compounds described in any of the above methods may be protected with any convenient amine protecting group, for example as described in Greene & Wuts, eds., “Protecting Groups in Organic Synthesis”, 2^(nd) ed. New York; John Wiley & Sons, Inc., 1991. Examples of amine protecting groups include acyl and alkoxycarbonyl groups, such as t-butoxycarbonyl (BOC), and [2-(trimethylsilyl)ethoxy]methyl (SEM). Likewise, carboxyl groups may be protected with any convenient carboxyl protecting group, for example as described in Greene & Wuts, eds., “Protecting Groups in Organic Synthesis”, 2^(nd) ed. New York; John Wiley & Sons, Inc., 1991. Examples of carboxyl protecting groups include (1-6C)alkyl groups, such as methyl, ethyl and t-butyl. Alcohol groups may be protected with any convenient alcohol protecting group, for example as described in Greene & Wuts, eds., “Protecting Groups in Organic Synthesis”, 2^(nd) ed. New York; John Wiley & Sons, Inc., 1991. Examples of alcohol protecting groups include benzyl, trityl, silyl ethers, and the like.

The ability of test compounds to act as ROS1 inhibitors may be demonstrated by the assay described in Example A. IC₅₀ values are shown in Table 17.

In some embodiments, inhibition of L2026M is similar to, or better than, that observed for wild-type ROS1. For example, inhibition of L2026M is within about 2-fold (e.g., about 5-fold, about 7-fold, about 10-fold) of inhibition of wild-type ROS1 (i.e. the compounds are similarly potent against wild-type ROS1 and L2026M). In some embodiments, inhibition of L2026M is about the same as inhibition of wild-type ROS1. In some embodiments, inhibition of L2026M is about 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold, 10-fold, or greater than inhibition of wild-type ROS1. In some embodiments, selectivity for a wildtype or L2026M ROS1 kinase over another kinase is measured in an enzyme assay (e.g., an enzyme assay as provided herein). In some embodiments, the compounds provided herein exhibit selective cytotoxicity to ROS1-mutant cells.

In some embodiments, inhibition of D2033N is similar to, or better than, that observed for wild-type ROS1. In some embodiments, inhibition of D2033N is within about 2-fold (e.g., about 5-fold, about 7-fold, about 10-fold) of inhibition of wild-type ROS1 (i.e. the compounds are similarly potent against wild-type ROS1 and D2033N). In some embodiments, inhibition of D2033N is about the same as inhibition of wild-type ROS1. In some embodiments, inhibition of D2033N is about 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold, 10-fold, or greater than inhibition of wild-type ROS1. In some embodiments, selectivity for a wildtype or D2033N ROS1 kinase over another kinase is measured in an enzyme assay (e.g., an enzyme assay as provided herein). In some embodiments, the compounds provided herein exhibit selective cytotoxicity to ROS1-mutant cells.

Compounds of Formula I are useful for treating diseases and disorders which can be treated with a ROS1 kinase inhibitor, such as ROS1-associated diseases and disorders, e.g., proliferative disorders such as cancers, including hematological cancers and solid tumors.

As used herein, terms “treat” or “treatment” refer to therapeutic or palliative measures. Beneficial or desired clinical results include, but are not limited to, alleviation, in whole or in part, of symptoms associated with a disease or disorder or condition, diminishment of the extent of disease, stabilized (i.e., not worsening) state of disease, delay or slowing of disease progression, amelioration or palliation of the disease state (e.g., one or more symptoms of the disease), and remission (whether partial or total), whether detectable or undetectable. “Treatment” can also mean prolonging survival as compared to expected survival if not receiving treatment.

As used herein, the terms “subject,” “individual,” or “patient,” are used interchangeably, refers to any animal, including mammals such as mice, rats, other rodents, rabbits, dogs, cats, swine, cattle, sheep, horses, primates, and humans. In some embodiments, the patient is a human. In some embodiments, the subject has experienced and/or exhibited at least one symptom of the disease or disorder to be treated and/or prevented. In some embodiments, the subject has been identified or diagnosed as having a cancer with a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same (a ROS1-associated cancer) (e.g., as determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit). In some embodiments, the assay is a liquid biopsy. In some embodiments, the subject has a tumor that is positive for a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same (e.g., as determined using a regulatory agency-approved assay or kit). The subject can be a subject with a tumor(s) that is positive for a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same (e.g., identified as positive using a regulatory agency-approved, e.g., FDA-approved, assay or kit). In some embodiments, the assay is a liquid biopsy. The subject can be a subject whose tumors have a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or a level of the same (e.g., where the tumor is identified as such using a regulatory agency-approved, e.g., FDA-approved, kit or assay). In some embodiments, the subject is suspected of having a ROS1-associated cancer. In some embodiments, the subject has a clinical record indicating that the subject has a tumor that has a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same (and optionally the clinical record indicates that the subject should be treated with any of the compositions provided herein). In some embodiments, the patient is a pediatric patient.

The term “pediatric patient” as used herein refers to a patient under the age of 21 years at the time of diagnosis or treatment. The term “pediatric” can be further be divided into various subpopulations including: neonates (from birth through the first month of life); infants (1 month up to two years of age); children (two years of age up to 12 years of age); and adolescents (12 years of age through 21 years of age (up to, but not including, the twenty-second birthday)). Berhman R E, Kliegman R, Arvin A M, Nelson W E. Nelson Textbook of Pediatrics, 15th Ed. Philadelphia: W.B. Saunders Company, 1996; Rudolph A M, et al. Rudolph's Pediatrics, 21st Ed. New York: McGraw-Hill, 2002; and Avery M D, First L R. Pediatric Medicine, 2nd Ed. Baltimore: Williams & Wilkins; 1994. In some embodiments, a pediatric patient is from birth through the first 28 days of life, from 29 days of age to less than two years of age, from two years of age to less than 12 years of age, or 12 years of age through 21 years of age (up to, but not including, the twenty-second birthday). In some embodiments, a pediatric patient is from birth through the first 28 days of life, from 29 days of age to less than 1 year of age, from one month of age to less than four months of age, from three months of age to less than seven months of age, from six months of age to less than 1 year of age, from 1 year of age to less than 2 years of age, from 2 years of age to less than 3 years of age, from 2 years of age to less than seven years of age, from 3 years of age to less than 5 years of age, from 5 years of age to less than 10 years of age, from 6 years of age to less than 13 years of age, from 10 years of age to less than 15 years of age, or from 15 years of age to less than 22 years of age.

In certain embodiments, compounds of Formula I are useful for preventing diseases and disorders as defined herein (for example, cancer). The term “preventing” as used herein means the prevention of the onset, recurrence or spread, in whole or in part, of the disease or condition as described herein, or a symptom thereof.

The term “ROS1-associated disease or disorder” as used herein refers to diseases or disorders associated with or having a dysregulation of a ROS1 gene, a ROS1 kinase (also called herein ROS1 kinase protein), or the expression or activity or level of any (e.g., one or more) of the same (e.g., any of the types of dysregulation of a ROS1 gene, a ROS1 kinase, a ROS1 kinase domain, or the expression or activity or level of any of the same described herein). A non-limiting example of a ROS1-associated disease or disorder includes cancer.

The term “ROS1-associated cancer” as used herein refers to cancers associated with or having a dysregulation of a ROS1 gene, a ROS1 kinase (also called herein ROS1 kinase protein), or expression or activity, or level of any of the same. Non-limiting examples of a ROS1-associated cancer are described herein.

The phrase “dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same” refers to a genetic mutation (e.g., a ROS1 gene translocation that results in the expression of a fusion protein, a deletion in a ROS1 gene that results in the expression of a ROS1 protein that includes a deletion of at least one amino acid as compared to the wild-type ROS1 protein, a mutation in a ROS1 gene that results in the expression of a ROS1 protein with one or more point mutations, or an alternative spliced version of a ROS1 mRNA that results in a ROS1 protein having a deletion of at least one amino acid in the ROS1 protein as compared to the wild-type ROS1 protein) or a ROS1 gene amplification that results in overexpression of a ROS1 protein or an autocrine activity resulting from the overexpression of a ROS1 gene in a cell that results in a pathogenic increase in the activity of a kinase domain of a ROS1 protein (e.g., a constitutively active kinase domain of a ROS1 protein) in a cell. As another example, a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same, can be a mutation in a ROS1 gene that encodes a ROS1 protein that is constitutively active or has increased activity as compared to a protein encoded by a ROS1 gene that does not include the mutation. For example, a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same, can be the result of a gene or chromosome translocation which results in the expression of a fusion protein that contains a first portion of ROS1 that includes a functional kinase domain, and a second portion of a partner protein that is not ROS1. In some examples, dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity or level of any of the same can be a result of a gene translocation of one ROS1 gene with another non-ROS1 gene. Non-limiting examples of fusion proteins are described in Table 2. Non-limiting examples of ROS1 kinase protein point mutations are described in Table 3 and Table 3a. Additional examples of ROS1 kinase protein mutations (e.g., point mutations) are ROS1 inhibitor resistance mutations. Non-limiting examples of ROS1 inhibitor resistance mutations are described in Table 4.

The term “wildtype” or “wild-type” when referring to a ROS1 nucleic acid or protein describes a nucleic acid (e.g., a ROS1 gene or a ROS1 mRNA) or protein (e.g., a ROS1 protein) that is found in a subject that does not have a ROS1-associated disease, e.g., a ROS1-associated cancer (and optionally also does not have an increased risk of developing a ROS1-associated disease and/or is not suspected of having a ROS1-associated disease), or is found in a cell or tissue from a subject that does not have a ROS1-associated disease, e.g., a ROS1-associated cancer (and optionally also does not have an increased risk of developing a ROS1-associated disease and/or is not suspected of having a ROS1-associated disease).

The term “regulatory agency” refers to a country's agency for the approval of the medical use of pharmaceutical agents with the country. For example, a non-limiting example of a regulatory agency is the U.S. Food and Drug Administration (FDA).

Provided herein is a method of treating cancer (e.g., a ROS1-associated cancer) in a patient in need of such treatment, the method comprising administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof. For example, provided herein are methods for treating a ROS1-associated cancer in a patient in need of such treatment, the method comprising a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the patient; and b) administering a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same includes one or more fusion proteins. Non-limiting examples of ROS1gene fusion proteins are described in Table 2. In some embodiments, the fusion protein is one of SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same includes one or more ROS1 kinase protein point mutations, insertions, and/or deletions. Non-limiting examples of ROS1 kinase protein point mutations are described in Table 3 and Table 3a. In some embodiments, the ROS1 kinase protein point mutations, insertions, and/or deletions are point mutations selected from the group consisting of A15G, R118N, G1025R, T1735M, R1948H, and R2072N. In some embodiments, a compound of Formula I is selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof.

In some embodiments of any of the methods or uses described herein, the cancer (e.g., ROS1-associated cancer) is a hematological cancer. In some embodiments of any of the methods or uses described herein, the cancer (e.g., ROS1-associated cancer) is a solid tumor. In some embodiments of any of the methods or uses described herein, the cancer (e.g., ROS1-associated cancer) is lung cancer (e.g., small cell lung carcinoma or non-small cell lung carcinoma), papillary thyroid cancer, medullary thyroid cancer, differentiated thyroid cancer, recurrent thyroid cancer, refractory differentiated thyroid cancer, lung adenocarcinoma, bronchioles lung cell carcinoma, multiple endocrine neoplasia type 2A or 2B (MEN2A or MEN2B, respectively), pheochromocytoma, parathyroid hyperplasia, breast cancer, colorectal cancer (e.g., metastatic colorectal cancer), papillary renal cell carcinoma, ganglioneuromatosis of the gastroenteric mucosa, inflammatory myofibroblastic tumor, or cervical cancer. In some embodiments of any of the methods or uses described herein, the cancer (e.g., ROS1-associated cancer) is selected from the group of: acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), cancer in adolescents, adrenocortical carcinoma, anal cancer, appendix cancer, astrocytoma, atypical teratoid/rhabdoid tumor, basal cell carcinoma, bile duct cancer, bladder cancer, bone cancer, brain stem glioma, brain tumor, breast cancer, bronchial tumor, Burkitt lymphoma, carcinoid tumor, unknown primary carcinoma, cardiac tumors, cervical cancer, childhood cancers, chordoma, chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), chronic myeloproliferative neoplasms, colon cancer, colorectal cancer, craniopharyngioma, cutaneous T-cell lymphoma, bile duct cancer, ductal carcinoma in situ, embryonal tumors, endometrial cancer, ependymoma, esophageal cancer, esthesioneuroblastoma, Ewing sarcoma, extracranial germ cell tumor, extragonadal germ cell tumor, extrahepatic bile duct cancer, eye cancer, fallopian tube cancer, fibrous histiocytoma of bone, gallbladder cancer, gastric cancer, gastrointestinal carcinoid tumor, gastrointestinal stromal tumors (GIST), germ cell tumor, gestational trophoblastic disease, glioma, hairy cell tumor, hairy cell leukemia, head and neck cancer, heart cancer, hepatocellular cancer, histiocytosis, Hodgkin's lymphoma, hypopharyngeal cancer, intraocular melanoma, islet cell tumors, pancreatic neuroendocrine tumors, Kaposi sarcoma, kidney cancer, Langerhans cell histiocytosis, laryngeal cancer, leukemia, lip and oral cavity cancer, liver cancer, lung cancer, lymphoma, macroglobulinemia, malignant fibrous histiocytoma of bone, osteocarcinoma, melanoma, Merkel cell carcinoma, mesothelioma, metastatic squamous neck cancer, midline tract carcinoma, mouth cancer, multiple endocrine neoplasia syndromes, multiple myeloma, mycosis fungoides, myelodysplastic syndromes, myelodysplastic/myeloproliferative neoplasms, myelogenous leukemia, myeloid leukemia, multiple myeloma, myeloproliferative neoplasms, nasal cavity and paranasal sinus cancer, nasopharyngeal cancer, neuroblastoma, non-Hodgkin's lymphoma, non-small cell lung cancer, oral cancer, oral cavity cancer, lip cancer, oropharyngeal cancer, osteosarcoma, ovarian cancer, pancreatic cancer, papillomatosis, paraganglioma, paranasal sinus and nasal cavity cancer, parathyroid cancer, penile cancer, pharyngeal cancer, pheochromosytoma, pituitary cancer, plasma cell neoplasm, pleuropulmonary blastoma, pregnancy and breast cancer, primary central nervous system lymphoma, primary peritoneal cancer, prostate cancer, rectal cancer, renal cell cancer, retinoblastoma, rhabdomyosarcoma, salivary gland cancer, sarcoma, Sezary syndrome, skin cancer, small cell lung cancer, small intestine cancer, soft tissue sarcoma, squamous cell carcinoma, squamous neck cancer, stomach cancer, T-cell lymphoma, testicular cancer, throat cancer, thymoma and thymic carcinoma, thyroid cancer, transitional cell cancer of the renal pelvis and ureter, unknown primary carcinoma, urethral cancer, uterine cancer, uterine sarcoma, vaginal cancer, vulvar cancer, and Wilms' tumor.

In some embodiments, a hematological cancer (e.g., hematological cancers that are ROS1-associated cancers) is selected from the group consisting of leukemias, lymphomas (non-Hodgkin's lymphoma), Hodgkin's disease (also called Hodgkin's lymphoma), and myeloma, for instance, acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), acute promyelocytic leukemia (APL), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML), chronic myelomonocytic leukemia (CMML), chronic neutrophilic leukemia (CNL), acute undifferentiated leukemia (AUL), anaplastic large-cell lymphoma (ALCL), prolymphocytic leukemia (PML), juvenile myelomonocyctic leukemia (JMML), adult T-cell ALL, AML with trilineage myelodysplasia (AML/TMDS), mixed lineage leukemia (MLL), myelodysplastic syndromes (MDSs), myeloproliferative disorders (MPD), and multiple myeloma (MM). Additional examples of hematological cancers include myeloproliferative disorders (MPD) such as polycythemia vera (PV), essential thrombocytopenia (ET) and idiopathic primary myelofibrosis (IMF/IPF/PMF). In some embodiments, the hematological cancer (e.g., the hematological cancer that is a RET-associated cancer) is AML or CMML.

In some embodiments, the cancer (e.g., the ROS1-associated cancer) is a solid tumor. Examples of solid tumors (e.g., solid tumors that are ROS1-associated cancers) include, for example, thyroid cancer (e.g., papillary thyroid carcinoma, medullary thyroid carcinoma), lung cancer (e.g., lung adenocarcinoma, small-cell lung carcinoma), pancreatic cancer, pancreatic ductal carcinoma, breast cancer, colon cancer, colorectal cancer, prostate cancer, renal cell carcinoma, head and neck tumors, neuroblastoma, and melanoma. See, for example, Nature Reviews Cancer, 2014, 14, 173-186.

In some embodiments, the cancer is selected from the group consisting of lung cancer (including, e.g., non-small-cell lung cancer), colorectal cancer, gastric cancer, adenocarcinoma (including, e.g., small bowel adenocarcinoma), cholangiocarcinoma, glioblastoma, ovarian cancer, angiocarcinoma, congenital gliobastoma multiforme, papillary thyroid carcinoma, inflammatory myofibroblastic tumour, a spitzoid neoplasm, anaplastic large cell lymphoma, diffuse large B cell lymphoma, and B-cell acute lymphoblastic leukemia.

In some embodiments, the patient is a human.

Compounds of Formula I and pharmaceutically acceptable salts and solvates thereof are also useful for treating a ROS1-associated cancer.

Accordingly, also provided herein is a method for treating a patient diagnosed with or identified as having a ROS1-associated cancer, e.g., any of the exemplary ROS1-associated cancers disclosed herein, comprising administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, or a pharmaceutical composition thereof as defined herein.

Dysregulation of a ROS1 kinase, a ROS1 gene, or the expression or activity or level of any (e.g., one or more) of the same can contribute to tumorigenesis. For example, a dysregulation of a ROS1 kinase, a ROS1 gene, or expression or activity or level of any of the same can be a translocation, overexpression, activation, amplification, or mutation of a ROS1 kinase, a ROS1 gene, or a ROS1 kinase domain. A translocation can include a translocation involving the ROS1 kinase domain, a mutation can include a mutation involving the ROS1 ligand-binding site, and an amplification can be of a ROS1 gene.

In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes overexpression of wild-type ROS1 kinase (e.g., leading to autocrine activation). In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase protein, or expression or activity or level of any of the same, includes overexpression, activation, amplification, or mutation in a chromosomal segment comprising the ROS1 gene or a portion thereof, including, for example, the kinase domain portion, or a portion capable of exhibiting kinase activity.

In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase protein, or expression or activity or level of any of the same, includes one or more chromosome translocations or inversions resulting in a ROS1 gene fusion. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase protein, or expression or activity or level of any of the same, is a result of genetic translocations in which the expressed protein is a fusion protein containing residues from a non-ROS1 partner protein, and includes a minimum of a functional ROS1 kinase domain.

Non-limiting examples of ROS1 fusion proteins are shown in Table 2.

TABLE 2 Exemplary ROS1 Fusion Proteins CD74 Non-small-cell lung cancer¹ SLC34A2 including Non-small-cell lung cancer¹, SLC34A2-ROS(S)²⁸, Colorectal cancer¹⁴, Gastric SLC34A2-ROS(L)²⁸, cancer¹⁵, Lung adenocarcinoma²⁴ and SLC34A2- ROS(VS)²⁸, SLC34A2-ROS (with a breakpoint at chr6: 117653720, chr4: 25678781)²⁴ TPM3 Non-small-cell lung cancer¹ SDC4 Non-small-cell lung cancer¹, Adenocarcinoma¹⁰ EZR Non-small-cell lung cancer¹ LRIG3 Non-small-cell lung cancer¹ KDELR2 Non-small-cell lung cancer¹ CCDC6 Non-small-cell lung cancer¹ FIG (GOPC, PIST) Non-small-cell lung cancer², including FIG- Cholangiocarcinoma⁵, ROS1(L)²⁹, FIG- Glioblastoma⁸, Ovarian cancer¹⁶, ROS1(S)²⁹, and FIG- Small bowel adenocarcinomas ROS1(VL)²⁹, FIG- (SBAs)²², Acral lentiginous ROS1 (XL)³⁰ melanoma (ALM)²⁵ TPD52L1 Non-small-cell lung cancer³ CEP85L Angiosarcoma⁴ Pediatric gliomas³¹ ZCCHC8 Congenital gliobastoma multiforme⁶ CCDC30 Papillary thyroid carcinoma⁷ TFG Inflammatory myofibroblastic tumour⁹, Sarcomas²⁶ TMEM106B Adenocarcinoma¹¹ YWHAE Inflammatory myofibroblastic tumor¹² MSN Lung cancer¹³ PWWP2A Spitzoid neoplasm¹⁷ FYN Non-small-cell lung cancer¹⁸ MKX Non-small-cell lung cancer¹⁸ PPFIBP1 Spitzoid neoplasm¹⁹ ERC1 Spitzoid neoplasm¹⁹ MY05A Spitzoid neoplasm¹⁹ CLIP1 Spitzoid neoplasm¹⁹ HLA-A Spitzoid neoplasm¹⁹ KIAA1598 (SHTN1) Spitzoid neoplasm¹⁹ ZCCHC8 Spitzoid neoplasm¹⁹ CLTC Non-small-cell lung cancer²⁰ LIMA1 Non-small-cell lung cancer²⁰ NFkB2 Anaplastic Large Cell Lymphoma²¹ NCOR2 Anaplastic Large Cell Lymphoma²¹ KLC1 Pediatric low-grade glioma²⁴ TBL1XR1 Juvenile myelomonocytic leukemia (JMML)²⁷ ¹Davies and Dobele, Clin. Cancer Res, 19(15):4040-5, 2013. ²Rimkunas et al., Clin. Cancer Res., 18:4449-58, 2012. ³Zhu et al., Lung Cancer, 97:48-50, doi: 10.1016/j.lungcan.2016.04.013, 2012. ⁴Giacomini et al., PLoS Gene.t, 9(4):e1003464, 2013. ⁵Saborowski et al., Proc. Natl. Acad. Sci. U.S.A., 110(48):19513-19518, 2013. ⁶Cocce et al., Genes Chromosomes Cancer, 55(9):677-87, 2016. ⁷Ritterhouse et al., Thyroid, 26(6):794-7, 2016. ⁸Das et al., Cancer Growth Metastasis, 8:51-60, doi: 10.4137/CGM.S32801, 2015. ⁹Yamamoto et al., Histopathology, 69(1):72-83, 2016. ¹⁰Fu et al., PLoS One, 10(4):e0124354, 2015. ¹¹Ou et al., Lung Cancer, 88(3):352-4, 2015. ¹²Hornick et al., Mod. Pathol., 28(5):732-9, 2015. ¹³Zheng et al., Nat Med., (12):1479-84, 2014. ¹⁴Aisner et al., Mol. Cancer Res., 12(1):111-8, 2014. ¹⁵Lee et al., Cancer, 119(9):1627-1635, 2013. ¹⁶Birch et al., PLoS One, 6(12):e28250, 2011. ¹⁷Weisner et al., Nature Comm., 5:3116, doi:10.1038/ncomms4116, 2014. ¹⁸U.S. Patent Application Publication No. 2016/0032396A1. ¹⁹PCT Patent Application Publication No. WO 2014/130975A1. ²⁰Australian Patent Application Publication No. AU 2015/101722A4 ²¹Crescenzo et al., Cancer Cell., 27(4):516-32, 2015. ²²Schrock et al., Annals of Oncology. Vol. 27, Supp_6, 613O, 2016. ²⁴Nakano etal. Pediatr Blood Cancer. Vol. 64, S54-S55 Suppe. 4. O13-1-7, 2017. ²⁵Couts et al. Pigment Cell Melanoma Res. Vol. 30, No. 5, pp. e61, 2017. ²⁶Ikeda et al. Annals of Oncology. Vol. 28 (suppl_10): x1-x6.10.1093/annonc/mdx652, 2017. ²⁷Murakami et al. Blood, blood-2017-07-798157; DOI: 10.1182/blood-2017-07-798157, 2018. ²⁸EP Patent Application Publication No. EP3266795A1 ²⁹U.S. Patent Publication No. US9782400B2 ³⁰PCT Patent Application Publication No. WO 2010/093928 ³¹Johnson et al., Oncologist. 22(12):1478-1490, doi:10.1634/theoncologist.2017-0242, 2017.

In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes one or more deletions, insertions, or point mutation(s) in a ROS1 kinase. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes a deletion of one or more residues from the ROS1 kinase, resulting in constitutive activity of the ROS1 kinase domain.

In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes at least one point mutation in a ROS1 gene that results in the production of a ROS1 kinase that has one or more amino acid substitutions, insertions, or deletions as compared to the wild-type ROS1 kinase (see, for example, the point mutations listed in Table 3).

TABLE 3 Exemplary ROS1 Point Mutations ROS1 Mutation ROS1-Associated Cancer Amino acid position 15 Diffuse large B cell (e.g., A15G) lymphoma¹ Amino acid position 118 B-cell acute lymphoblastic (e.g., R118N) leukemia² Amino acid position 122 Gastrointestinal stromal (e.g., A122T) tumors (GISTs)³ Amino acid position 245 Uterine Corpus (e.g., R245I) Endometrioid Carcinoma⁴ Amino acid position 1025 B-cell acute lymphoblastic (e.g., G1025R) leukemia² Amino acid position 1186 Non-Small-Cell Lung (e.g., S1186F) Cancer⁵ Amino acid position 1539 Skin Cutaneous (e.g., P1539S) Melanoma⁷ Amino acid position 1735 B-cell acute lymphoblastic (e.g., T1735M) leukemia² Amino acid position 1948 Diffuse large B cell (e.g., R1948H) lymphoma¹ Amino acid position 2033 Colorectal (e.g., D2033Y) adenocarcinoma⁶ Amino acid position 2072 B-cell acute lymphoblastic (e.g., R2072N) leukemia² Amino acid position 2126 Breast, melanoma⁶ (e.g., R2126W, R2126Q, R2126L) Amino acid position 2308 Kidney renal clear cell (e.g., E2308, carcinoma, Skin cutaneous E2308Q) melanoma, Head and neck squamous cell carcinoma ⁷ ¹U.S. Patent Application Publication No. 2016/0032404A1. ²de Smith et al., Oncotarget., doi: 10.18632/oncotarget.12238, 2016. ³Qiu et al., J. Clin. Oncol. 35:15_suppl, e22507-e22507, 2017. ⁴PCT Patent Application Publication No. WO 2016/187508A2 ⁵Gainor et al., JCO Precis Oncol. 10.1200/PO.17.00063, 2017. ⁶The Cancer Genome Atlas: http://cancergenome.nih.gov/ ⁷Wang, University of Hong Kong, Pokfulam, Hong Kong SAR (Thesis). Retrieved from http://dx.doi.org/10.5353/th_b5659723.

Additional exemplary ROS1 mutations are provided in Table 3a.

TABLE 3a Exemplary ROS1 Mutations Amino acid position 1186 (e.g., S1186F¹¹) Amino acid position 1935 (e.g., E1935G6¹⁰) Amino acid position 1945 (e.g., L1945Q⁷) Amino acid position 1946 (e.g., T1946S⁷) Amino acid position 1947 (e.g., L1947R^(6,10), L1947M⁷) Amino acid position 1948 (e.g., R1948S⁷) Amino acid position 1951 (e.g., L1951R⁵, L1951V⁷) Amino acid position 1958 (e.g., E1958V⁷) Amino acid position 1959 (e.g., V1959E⁷) Amino acid position 1961 (e.g., E1961K⁷) Amino acid position 1962 (e.g., G1962E⁷) Amino acid position 1971 (e.g., G1971E^(6,10)) Amino acid position 1974 (e.g., E1974K⁹) Amino acid position 1981 (e.g., T1981M⁷) Amino acid position 1982 (e.g., L1982F^(5,10), L1982R⁶) Amino acid position 1986 (e.g., S1986Y¹, S1986F¹) Amino acid position 1990 (e.g., E1990G⁵, E1990L⁷) Amino acid position 1993 (e.g., E1993K⁷) Amino acid position 1994 (e.g., F1994L⁵) Amino acid position 2000 (e.g., L2000V⁷) Amino acid position 2002 (e.g., S2002N⁷) Amino acid position 2004 (e.g., F2004L⁷, F2004I⁹, F2004V⁹, F2004C⁹) Amino acid position 2008 (e.g., N2008H⁷) Amino acid position 2009 (e.g., I2009L⁷) Amino acid position 2010 (e.g., L2010M⁷) Amino acid position 2011 (e.g., K2011N⁷) Amino acid position 2016 (e.g., C2016G⁷) Amino acid position 2019 (e.g., N2019D⁷, N2019Y⁷) Amino acid position 2020 (e.g., E2020k⁹) Amino acid position 2022 (e.g., Q2022H⁷) Amino acid position 2026 (e.g., L2026M³) Amino acid position 2028 (e.g., L2028M⁷) Amino acid position 2029 (e.g., M2029K⁷) Amino acid position 2030 (e.g., E2030K⁷) Amino acid position 2032 (e.g., G2032R²) Amino acid position 2033 (e.g., D2033G⁷, D2033N⁸) Amino acid position 2035 (e.g., L2035I⁷) Amino acid position 2036 (e.g., T2036I⁷, T2036N⁷) Amino acid position 2039 (e.g., R2039G⁷, R2039H⁷, R2039M⁷, R2039N⁷, R2039S⁷) Amino acid position 2040 (e.g., K2040E⁷, K2040Q⁷) Amino acid position 2052 (e.g., T2052S⁷) Amino acid position 2059 (e.g., L2059P⁷) Amino acid position 2060 (e.g., C2060G^(6,10)) Amino acid position 2075 (e.g., F2075C⁹, F2075I⁹, F2075V⁹) Amino acid position 2077 (e.g., H2077P⁷) Amino acid position 2078 (e.g., R2078W⁷) Amino acid position 2087 (e.g., V2087I⁷) Amino acid position 2091 (e.g., D2091N⁷) Amino acid position 2092 (e.g., Y2092N⁷) Amino acid position 2094 (e.g., S2094N⁷) Amino acid position 2098 (e.g., V2098I^(6,10)) Amino acid position 2099 (e.g., K2099N⁷) Amino acid position 2100 (e.g., I2100V⁷) Amino acid position 2101 (e.g., G2101A⁷) Amino acid position 2106 (e.g., A2106P⁷) Amino acid position 2107 (e.g., R2107T⁷) Amino acid position 2112 (e.g., N2112K⁹) Amino acid position 2113 (e.g., D2113N⁹ D2113G⁹) Amino acid position 2116 (e.g., R2116T⁷, R2116K⁹) Amino acid position 2125 (e.g., V2125G⁷, V2125L⁷) Amino acid position 2127 (e.g., W2127G⁷, W2127⁹) Amino acid position 2128 (e.g., M2128T⁹) Amino acid position 2131 (e.g., E2131D⁷, E2131K⁷) Amino acid position 2134 (e.g., M2134I⁷) Amino acid position 2139 (e.g., T2139I⁷, T2139S⁷) Amino acid position 2141 (e.g., Q2141H⁷) Amino acid position 2142 (e.g., S2142Y⁷) Amino acid position 2148 (e.g., G2148E⁷) Amino acid position 2151 (e.g., I2151N⁷) Amino acid position 2154 (e.g., I2154M⁷) Amino acid position 2155 (e.g., L2155S⁴) Amino acid position 2160 (e.g., Q2160H⁷) Amino acid position 2165 (e.g., H2165D⁷) Amino acid position 2181 (e.g., E2181D⁷) Amino acid position 2184 (e.g., R2184T⁷) Amino acid position 2201 (e.g., E2201D⁷) Amino acid position 2205 (e.g., R2205I⁷) Amino acid position 2207 (e.g., T2207I⁷) Amino acid position 2209 (e.g., H2209P⁷) Amino acid position 2212 (e.g., Q2212H⁷, Q2212P⁷) Amino acid position 2223 (e.g., L2223⁹) Amino acid position 2224 (e.g., N2224K⁹) ¹Facchinetti et al., Clin. Cancer Res., DOI: 10.1158/1078-0432.CCR-16-0917, 2016. ²Awad et al., N. Engl. J. Med., 368(25):2395-401, 2013. ³Zou et al., Proc. Natl. Acad. Sci. U.S.A., 112(11):3493-8, 2015 ⁴Song et al., Clin. Cancer Res., 21(10):2379-87, 2015. ⁵Katayama et al., Clin. Cancer Res., 21(1):166-74, 2015. ⁶PCT Patent Application Publication No. WO 2014/134096A1. ⁷PCT Patent Application Publication No. WO 2014/152777A2. ⁸Drilon et al., Clin. Cancer Res., 22(10):2351-8, 2016. ⁹Davare etal., Proc. Natl. Acad. Sci. U.S.A., 112(39):E5381-90, 2015. ¹⁰Davare etal., Proc. Natl. Acad. Sci. U.S.A., 110(48):19519-24, 2013. ¹¹Gainor et al., JCO Precis Oncol. 10.1200/PO.17.00063, 2017.

In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes a splice variation in a ROS1 mRNA which results in an expressed protein that is an alternatively spliced variant of ROS1 having at least one residue deleted (as compared to the wild-type ROS1 kinase) resulting in a constitutive activity of a ROS1 kinase domain. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes a splice variation in a ROS1 mRNA which results in an expressed protein that is an alternatively spliced variant of ROS1 having at least one residue added (as compared to the wild-type ROS1 kinase) resulting in a constitutive activity of a ROS1 kinase domain.

A “ROS1 kinase inhibitor” as defined herein includes any compound exhibiting ROS1 inhibition activity. In some embodiments, a ROS1 kinase inhibitor is selective for a wild type and/or mutant ROS1 kinase. In some embodiments, ROS1 kinase inhibitors can exhibit inhibition activity (IC₅₀) against a ROS1 kinase of less than about 1000 nM, less than about 500 nM, less than about 200 nM, less than about 100 nM, less than about 50 nM, less than about 25 nM, less than about 10 nM, or less than about 1 nM as measured in an assay as described herein. In some embodiments, a ROS1 kinase inhibitors can exhibit inhibition activity (IC₅₀) against a ROS1 kinase of less than about 25 nM, less than about 10 nM, less than about 5 nM, or less than about 1 nM as measured in an assay as provided herein. In some embodiments, the ROS1 kinase inhibitor is a compound of Formula I.

As used herein, a “first ROS1 kinase inhibitor” or “first ROS1 inhibitor” is a ROS1 kinase inhibitor as defined herein, but which does not include a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as defined herein. As used herein, a “second ROS1 kinase inhibitor” or a “second ROS1 inhibitor” is a ROS1 kinase inhibitor as defined herein. In some embodiments, a second ROS1 inhibitor does not include a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as defined herein. When more than one ROS1 inhibitor is present in a method provided herein (e.g., both a first and a second ROS1 inhibitor are present in a method provided herein), the two ROS1 inhibitors are different (e.g., the first and second ROS1 kinase inhibitor are different). As provided herein, different ROS1 inhibitors are structurally distinct from one another.

In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes at least one point mutation in a ROS1 gene that results in the production of a ROS1 kinase that has one or more amino acid substitutions or insertions or deletions as compared to the wild-type ROS1 kinase. In some cases, the resulting ROS1 kinase is more resistant to inhibition of its phosphotransferase activity by one or more first ROS1 kinase inhibitor(s), as compared to a wildtype ROS1 kinase or a ROS1 kinase not including the same mutation. Such mutations, optionally, do not decrease the sensitivity of the cancer cell or tumor having the ROS1 kinase to treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof (e.g., as compared to a cancer cell or a tumor that does not include the particular ROS1 inhibitor resistance mutation). In such embodiments, a ROS1 inhibitor resistance mutation can result in a ROS1 kinase that has one or more of an increased V_(max), a decreased K_(m) for ATP, and an increased K_(D) for a first ROS1 kinase inhibitor, when in the presence of a first ROS1 kinase inhibitor, as compared to a wildtype ROS1 kinase or a ROS1 kinase not having the same mutation in the presence of the same first ROS1 kinase inhibitor.

In other embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, includes at least one point mutation in a ROS1 gene that results in the production of a ROS1 kinase that has one or more amino acid substitutions as compared to the wild-type ROS1 kinase, and which has increased resistance to a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, as compared to a wildtype ROS1 kinase or a ROS1 kinase not including the same mutation. In such embodiments, a ROS1 inhibitor resistance mutation can result in a ROS1 kinase that has one or more of an increased V_(max), a decreased K_(m), and a decreased K_(D) in the presence of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, as compared to a wildtype ROS1 kinase or a ROS1 kinase not having the same mutation in the presence of the same compound of Formula I or a pharmaceutically acceptable salt or solvate thereof.

Examples of ROS1 inhibitor resistance mutations can, e.g., include point mutations, insertions, or deletions in and near the ATP binding site in the tertiary structure of ROS1 kinase, including but not limited to the gatekeeper residue, P-loop residues, residues in or near the DFG motif, and ATP cleft solvent front amino acid residues. Additional examples of these types of mutations include changes in residues that may affect enzyme activity and/or drug binding including but are not limited to residues in the activation loop, residues near or interacting with the activation loop, residues contributing to active or inactive enzyme conformations, changes including mutations, deletions, and insertions in the loop proceeding the C-helix and in the C-helix. Specific residues or residue regions that may be changed (e.g., ROS1 inhibitor resistance mutations) include but are not limited to those listed in Table 4 based on the human wildtype ROS1 protein sequence (e.g., SEQ ID NO: 1). Changes to these residues may include single or multiple amino acid changes, insertions within or flanking the sequences, and deletions within or flanking the sequences.

In some embodiments, compounds of Formula I and pharmaceutically acceptable salts and solvates are useful in treating patients that develop cancers with ROS1 inhibitor resistance mutations (e.g., that result in an increased resistance to a first ROS1 inhibitor, e.g., a substitution at amino acid position 2032 (e.g., G2032R), amino acid position 2026 (e.g., L2026M), amino acid position 2033 (e.g., D2033N), and/or one or more ROS1 inhibitor resistance mutations listed in Table 4) by either dosing in combination or as a follow-up therapy to existing drug treatments (e.g., ALK kinase inhibitors, TRK kinase inhibitors, other ROS1 kinase inhibitors, e.g., first and/or second ROS1 kinase inhibitors). Exemplary ALK kinase inhibitors are described herein. Exemplary TRK kinase inhibitors are described herein. Exemplary first and second ROS1 kinase inhibitors are described herein. In some embodiments, a first or second ROS1 kinase inhibitor can be selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib.

In some embodiments, compounds of Formula I or pharmaceutically acceptable salts and solvates thereof are useful for treating a cancer that has been identified as having one or more ROS1 inhibitor resistance mutations (that result in an increased resistance to a first or second ROS1 inhibitor, e.g., a substitution at amino acid position 2032 (e.g., G2032R), amino acid position 2026 (e.g., L2026M), amino acid position 2033 (e.g., D2033N)). Non-limiting examples of ROS1 inhibitor resistance mutations are listed in Table 4.

TABLE 4 Exemplary ROS1 Resistance Mutations Amino acid position 1186 (e.g., S1186F¹¹) Amino acid position 1935 (e.g., E1935G6¹⁰) Amino acid position 1945 (e.g., L1945Q⁷) Amino acid position 1946 (e.g., T1946S⁷) Amino acid position 1947 (e.g., L1947R^(6,10), L1947M⁷) Amino acid position 1948 (e.g., R1948S⁷) Amino acid position 1951 (e.g., L1951R⁵, L1951V⁷) Amino acid position 1958 (e.g., E1958V⁷) Amino acid position 1959 (e.g., V1959E⁷) Amino acid position 1961 (e.g., E1961K⁷) Amino acid position 1962 (e.g., G1962E⁷) Amino acid position 1971 (e.g., G1971E^(6,10)) Amino acid position 1974 (e.g., E1974K⁹) Amino acid position 1981 (e.g., T1981M⁷) Amino acid position 1982 (e.g., L1982F^(5,10), L1982R⁶) Amino acid position 1986 (e.g., S1986Y¹, S1986F¹) Amino acid position 1990 (e.g., E1990G⁵, E1990L⁷) Amino acid position 1993 (e.g., E1993K⁷) Amino acid position 1994 (e.g., F1994L⁵) Amino acid position 2000 (e.g., L2000V⁷) Amino acid position 2002 (e.g., S2002N⁷) Amino acid position 2004 (e.g., F2004L⁷, F2004I⁹, F2004V⁹, F2004C⁹) Amino acid position 2008 (e.g., N2008H⁷) Amino acid position 2009 (e.g., I2009L⁷) Amino acid position 2010 (e.g., L2010M⁷) Amino acid position 2011 (e.g., K2011N⁷) Amino acid position 2016 (e.g., C2016G⁷) Amino acid position 2019 (e.g., N2019D⁷, N2019Y⁷) Amino acid position 2020 (e.g., E2020k⁹) Amino acid position 2022 (e.g., Q2022H⁷) Amino acid position 2026 (e.g., L2026M³) Amino acid position 2028 (e.g., L2028M⁷) Amino acid position 2029 (e.g., M2029K⁷) Amino acid position 2030 (e.g., E2030K⁷) Amino acid position 2032 (e.g., G2032R²) Amino acid position 2033 (e.g., D2033G⁷, D2033N⁸) Amino acid position 2035 (e.g., L2035I⁷) Amino acid position 2036 (e.g., T2036I⁷, T2036N⁷) Amino acid position 2039 (e.g., R2039G⁷, R2039EI⁷, R2039M⁷, R2039N⁷, R2039S⁷) Amino acid position 2040 (e.g., K2040E⁷, K2040Q⁷) Amino acid position 2052 (e.g., T2052S⁷) Amino acid position 2059 (e.g., L2059P⁷) Amino acid position 2060 (e.g., C2060G^(6,10)) Amino acid position 2075 (e.g., F2075C⁹, F2075I⁹, F2075V⁹) Amino acid position 2077 (e.g., H2077P⁷) Amino acid position 2078 (e.g., R2078W⁷) Amino acid position 2087 (e.g., V2087I⁷) Amino acid position 2091 (e.g., D2091N⁷) Amino acid position 2092 (e.g., Y2092N⁷) Amino acid position 2094 (e.g., S2094N⁷) Amino acid position 2098 (e.g., V2098I^(6,10)) Amino acid position 2099 (e.g., K2099N⁷) Amino acid position 2100 (e.g., I2100V⁷) Amino acid position 2101 (e.g., G2101A⁷) Amino acid position 2106 (e.g., A2106P⁷) Amino acid position 2107 (e.g., R2107T⁷) Amino acid position 2112 (e.g., N2112K⁹) Amino acid position 2113 (e.g., D2113N⁹ D2113G⁹) Amino acid position 2116 (e.g., R2116T⁷, R2116K⁹) Amino acid position 2125 (e.g., V2125G⁷, V2125L⁷) Amino acid position 2127 (e.g., W2127G⁷, W2127⁹) Amino acid position 2128 (e.g., M2128T⁹) Amino acid position 2131 (e.g., E2131D⁷, E2131K⁷) Amino acid position 2134 (e.g., M2134I⁷) Amino acid position 2139 (e.g., T2139I⁷, T2139S⁷) Amino acid position 2141 (e.g., Q2141H⁷) Amino acid position 2142 (e.g., S2142Y⁷) Amino acid position 2148 (e.g., G2148E⁷) Amino acid position 2151 (e.g., I2151N⁷) Amino acid position 2154 (e.g., I2154M⁷) Amino acid position 2155 (e.g., L2155S⁴) Amino acid position 2160 (e.g., Q2160H⁷) Amino acid position 2165 (e.g., H2165D⁷) Amino acid position 2181 (e.g., E2181D⁷) Amino acid position 2184 (e.g., R2184T⁷) Amino acid position 2201 (e.g., E2201D⁷) Amino acid position 2205 (e.g., R2205I⁷) Amino acid position 2207 (e.g., T2207I⁷) Amino acid position 2209 (e.g., H2209P⁷) Amino acid position 2212 (e.g., Q2212H⁷, Q2212P⁷) Amino acid position 2223 (e.g., L2223⁹) Amino acid position 2224 (e.g., N2224K⁹) ¹Facchinetti et al., Clin. Cancer Res., DOI: 10.1158/1078-0432.CCR-16-0917, 2016. ²Awad et al., N. Engl. J. Med., 368(25):2395-401, 2013. ³Zou et al., Proc. Natl. Acad. Sci. U.S.A., 112(11):3493-8, 2015. ⁴Song et al., Clin. Cancer Res., 21(10):2379-87, 2015. ⁵Katayama et al., Clin. Cancer Res., 21(1):166-74, 2015. ⁶PCT Patent Application Publication No. WO 2014/134096A1. ⁷PCT Patent Application Publication No. WO 2014/152777A2. ⁸Drilon et al., Clin. Cancer Res., 22(10):2351-8, 2016. ⁹Davare etal., Proc. Natl. Acad. Sci. U.S.A., 112(39):E5381-90, 2015. ¹⁰Davare etal., Proc. Natl. Acad. Sci. U.S.A., 110(48):19519-24, 2013. ¹¹Gainor et al., JCO Precis Oncol. 10.1200/PO.17.00063, 2017.

The ROS1 proto-oncogene is expressed in a variety of tumor types, and belongs to the sevenless subfamily of tyrosine kinase insulin receptor genes. The protein encoded by this gene is a type I integral membrane protein with tyrosine kinase activity. ROS1 shares structural similarity with the anaplastic lymphoma kinase (ALK) protein. Gene rearrangements involving ROS1 have been identified in a variety of cancers. The small molecule tyrosine kinase inhibitor, crizotinib, has been approved for the treatment of patients with metastatic NSCLC whose tumors are ROS1-positive or ALK-positive. Although the most preclinical and clinical studies of ROS1 gene fusions have been performed in lung cancer, ROS1 fusions have been detected in multiple other tumor histologies, including ovarian carcinoma, sarcoma, cholangiocarcinomas and others.

ALK is a receptor tyrosine kinase that belongs to the insulin growth factor receptor superfamily. ALK is believed to play a role in the development of the nervous system. A variety of ALK gene fusions have been described, such as EML4, KIF5B, KLC1, and TRK-fused gene (TFG). Such fusion products result in kinase activation and oncogenesis. Non-small-cell lung cancer (NSCLC) harboring the anaplastic lymphoma kinase gene (ALK) rearrangement is sensitive to the small molecule tyrosine kinase inhibitor crizotinib, which is an inhibitor of ALK and ROS1.

In some embodiments, the additional therapeutic agent(s) includes any one of the above listed therapies or therapeutic agents which are standards of care in cancers wherein the cancer has a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same. In some embodiments, the additional therapeutic agent(s) includes any one of the above listed therapies or therapeutic agents which are standards of care in cancers wherein the cancer has a dysregulation of an ALK gene, an ALK protein, or expression or activity, or level of any of the same (e.g., an ALK-associated cancer). In some embodiments, the additional therapeutic agent(s) includes any one of the above listed therapies or therapeutic agents which are standards of care in cancers wherein the cancer has a dysregulation of a TRK gene, a TRK protein, or expression or activity, or level of any of the same (e.g., a TRK-associated cancer).

The term “ALK-associated cancer” as used herein refers to cancers associated with or having a dysregulation of an ALK gene, an ALK protein, or expression or activity, or level of any of the same. Exemplary ALK-associated cancers are provided herein.

The phrase “dysregulation of an ALK gene, an ALK kinase, or the expression or activity or level of any of the same” refers to a genetic mutation (e.g., an ALK gene translocation that results in the expression of a fusion protein, a deletion in an ALK gene that results in the expression of an ALK protein that includes a deletion of at least one amino acid as compared to the wild-type ALK protein, a mutation in an ALK gene that results in the expression of an ALK protein with one or more point mutations, or an alternative spliced version of an ALK mRNA that results in an ALK protein having a deletion of at least one amino acid in the ALK protein as compared to the wild-type ALK protein) or an ALK gene amplification that results in overexpression of an ALK protein or an autocrine activity resulting from the overexpression of an ALK gene in a cell that results in a pathogenic increase in the activity of a kinase domain of an ALK protein (e.g., a constitutively active kinase domain of an ALK protein) in a cell. As another example, a dysregulation of an ALK gene, an ALK protein, or expression or activity, or level of any of the same, can be a mutation in an ALK gene that encodes an ALK protein that is constitutively active or has increased activity as compared to a protein encoded by an ALK gene that does not include the mutation. For example, a dysregulation of an ALK gene, an ALK protein, or expression or activity, or level of any of the same, can be the result of a gene or chromosome translocation which results in the expression of a fusion protein that contains a first portion of ALK that includes a functional kinase domain, and a second portion of a partner protein that is not ALK. In some examples, dysregulation of an ALK gene, an ALK protein, or expression or activity or level of any of the same can be a result of a gene translocation of one ALK gene with another non-ALK gene. Non-limiting examples of fusion proteins are described in Table 5. Additional examples of ALK kinase protein mutations (e.g., point mutations) are ALK inhibitor resistance mutations.

The term “wildtype” or “wild-type” when referring to an ALK nucleic acid or protein describes a nucleic acid (e.g., an ALK gene or an ALK mRNA) or protein (e.g., an ALK protein) that is found in a subject that does not have an ALK-associated disease, e.g., an ALK-associated cancer (and optionally also does not have an increased risk of developing an ALK-associated disease and/or is not suspected of having an ALK-associated disease), or is found in a cell or tissue from a subject that does not have an ALK-associated disease, e.g., an ALK-associated cancer (and optionally also does not have an increased risk of developing an ALK-associated disease and/or is not suspected of having an ALK-associated disease).

In some embodiments, the dysregulation of an ALK gene, an ALK kinase protein, or expression or activity or level of any of the same, includes one or more chromosome translocations or inversions resulting in an ALK gene fusion. In some embodiments, the dysregulation of an ALK gene, an ALK kinase protein, or expression or activity or level of any of the same, is a result of genetic translocations in which the expressed protein is a fusion protein containing residues from a non-ALK partner protein, and includes a minimum of a functional ALK kinase domain.

Non-limiting examples of ALK fusion proteins are shown in Table 5.

TABLE 5 Exemplary ALK Fusion Proteins ALK Partner ALK-Associated Cancer NPM/NPM1 Anaplastic large cell lymphoma¹, Diffuse large B-cell lymphoma¹, Neuroblastoma⁸, Lung adenocarcinoma⁹ ALO17/RNF213 Anaplastic large cell lymphoma¹ TFG (e.g., TFGs, Anaplastic large cell lymphoma¹, TFG_(L), TF GXL )³⁸ Non-small cell lung cancer¹, Anaplastic thyroid carcinoma¹ MSN (e.g., MSNa Anaplastic large cell lymphoma¹ and MSNb)³⁸ TPM3 Anaplastic large cell lymphoma¹, Inflammatory myofibroblastic tumour¹, Renal medulla carcinoma/renal cell carcinoma¹, Spitzoid neoplasm⁵ TPM4 (e.g., type 1 Anaplastic large cell lymphoma¹, and type 2)³⁸ Inflammatory myofibroblastic tumour¹, Oesophageal squamous cell carcinoma¹ ATIC Anaplastic large cell lymphoma¹. Inflammatory myofibroblastic tumour¹ MYH9 Anaplastic large cell lymphoma¹ CLTC Anaplastic large cell lymphoma¹, Inflammatory myofibroblastic tumour¹, Diffuse large B-cell lymphoma¹ TRAF1 Anaplastic large cell lymphoma¹ EML4* Non-small cell lung cancer¹, Renal medulla carcinoma/renal cell carcinoma¹, Breast cancer¹, Colon cancer¹, Anaplastic thyroid carcinoma¹, Squamous cell carcinoma¹⁴, Lung adenocarcinoma¹⁸, Colorectal Adenocarcinoma¹⁹ KIF5B Non-small cell lung cancer¹ KLC1 Non-small cell lung cancer¹ PTPN3 Non-small cell lung cancer¹ HIP1 Non-small cell lung cancer¹ TPR Non-small cell lung cancer¹ STRN Non-small cell lung cancer¹, Anaplastic thyroid carcinoma¹, Colorectal Adenocarcinoma¹⁹, Renal Cell Carcinoma²⁰ SEC31A/SEC31L1³⁸ Inflammatory myofibroblastic (e.g., type 1 and type tumour¹, Diffuse large B-cell 2)³⁸ lymphoma¹, Lung adenocarcinoma²¹ RANBP2 Inflammatory myofibroblastic tumour¹, Pediatric acute myeloid leukemia¹¹ PPFIBP1 Inflammatory myofibroblastic tumour¹ CARS Inflammatory myofibroblastic tumour¹ SQSTM1 Diffuse large B-cell lymphoma¹ VCL Renal medulla carcinoma/renal cell carcinoma¹ C2orf44 Colon cancer¹ FN1 Serous ovarian carcinoma¹, Gastrointestinal ¹eiomyoma³⁶ GFPT1 Anaplastic thyroid carcinoma¹ KIAA1618 Blood Cancer² MEL4 Unspecified³ ROS1 Unspecified⁴ DCTN1 Spitzoid neoplasm⁵, Sarcoma²⁶ MDCF2 Lung adenocarcinoma⁶ STK32B Breast cancer⁶ TPM1 Unspecified⁷ PRKAR1A Unspecified⁷ NCOA1 Unspecified⁷ GTF2IRD1 Unspecified⁷ CLTCL1 Neuroblastoma⁸ LMNA Neuroblastoma⁸ PRKAR1A Neuroblastoma⁸, Non-small cell lung cancer¹⁵, Colorectal Adenocarcinoma¹⁹ SPTBN1 Lung adenocarcinoma¹⁰ EIF2AK3 Lung adenocarincoma¹², Non-small cell lung cancer¹⁵ EML4-EXOC6B Lung adenocarincoma¹³ PPM1B Non-small cell lung cancer¹⁵ MALAT1 (lncRNA Triple-negative breast cancer¹⁶ gene fusion) HOOK1 Renal cell carcinoma¹⁷ CAD Colorectal Adenocarcinoma¹⁹ PPP1T21 Colorectal Adenocarcinoma¹⁹ SENPF Colorectal Adenocarcinoma¹⁹ MAPRE3 Colorectal Adenocarcinoma¹⁹ SPDYA Non-small cell lung cancer²² ASXL2 Non-small cell lung cancer²² IGL@ Diffuse large B-cell lymphoma²³ PPP1R21 Colorectal Adenocarcinoma²⁴ PRKAP1B Colorectal Adenocarcinoma²⁴ BIRC6 Non-small cell lung cancer²⁵ PICALM Non-small cell lung cancer²⁵ KCL Lung adenocarcinoma²⁷ CRIM1 Non-small cell lung cancer²⁸ EEF1G Anaplastic large cell lymphoma²⁹ DCTN1 Advanced Sarcoma³⁰, Inflammatory myofibroblastic tumor³³, Spitzoid tumors³³ GTF2IRD1 Pediatric, adolescent and young adult (PAYA) thyroid carcinoma³¹ BEND5 Neuroblastoma³² PPP1CB Astrocytoma³² CUX Non-small-cell Lung cancer³⁴ FAM179A Non-small-cell Lung cancer³⁵ COL25A1 Non-small-cell Lung cancer³⁵ BIRC6 Non-small-cell Lung Cancer³⁷ PICALM Non-small-cell Lung Cancer³⁷ GTF3C2 Spitz tumor³⁹ IGFBP5 Soft Tissue Sarcoma⁴⁰ MYO18A Adenosarcoma⁴¹ *There are a number of different ALK-EML4 fusion variants: 1, 2, 3a, 3b, 4, 5a, 5b, 6, 7, 8a, 8b, 4', 5' (Ann. Oncol., 27(3):iii6-iii24, 2016) ¹Hallberg and Palmer, Ann. Oncology, 27 (Suppl 3):iii4-iii15. doi: 10.1093/annonc/mdw301, 2016. ²U.S. Patent Publication No. 9,469,876B2. ³U.S. Patent Application Publication No. 2016/0145237A1. ⁴U.S. Patent Application Publication No. 2016/0108123A1. ⁵U.S. Patent Application Publication No. 2016/0010068A1. ⁶U.S. Patent Application Publication No. 2016/00009785A1. ⁷European Patent Application Publication No. 2986736A2. ⁸Katayama, et al. Clin Cancer Res, 21(10):2227-35, May 2015. ⁹Dacic et al., Oncotarget, 2016: doi: 10.18632/oncotarget.12705. ¹⁰Gu et al., J Hematol Oncol, 9(1): 66, 2016. ¹¹Hayashi et al., Blood Cancer J, 6(8): e456, 2016. ¹²Won et al., BMC Cancer, 16:568, 2016. ¹³Ma et al., Oncotarget, 2016, doi: 10.18632/oncotarget.10560. ¹⁴Yamamoto et al., Mol Clin. Oncol. 5(1): 61-63, 2016. ¹⁵Ali et al., Oncologist, 21(6): 762-70, 2016. ¹⁶Shaver et al., Cancer Res, 76(16): 4850-60, 2016. 17Cajaiba et al., Genes Chromosomes Cancer, 55(10): 814-7, 2016. ¹⁸Hainsworth et al., Drugs Real World Outcomes, 3:115-120, 2016. ¹⁹Yakirevich et al., Clin Cancer Res, 22(15): 3831-40, 2016. ²⁰Kusano, Am J. Surg Pathol. 40(6): 761-9, 2016. ²¹Kim et al., Cancer Res Treat, 48(1): 298-402, 2016. ²²Rosenbaum et al., Laboratory Investigation, Vol. 96, Supp. SUPPL. 1, pp. 481A-482A, Abstract Number: 1914, 105th Annual Meeting of the United States and Canadian Academy of Pathology, Seattle, WA, 2016. ²³Pan et al., Laboratory Investigation, Vol. 96, Supp. SUPPL. 1, pp. 367A, Abstract Number: 1450, 105th Annual Meeting of the United States and Canadian Academy of Pathology, Seattle, WA, 2016. ²⁴Yakirevich et al., Laboratory Investigation, Vol. 96, Supp. SUPPL. 1, pp. 209A, Abstract Number: 827, 105th Annual Meeting of the United States and Canadian Academy of Pathology, Seattle, WA, 2016. ²⁵Ying et al., J. Clin. Oncology, Vol. 34, Supp. Supplement 15, Abstract Number: e20506, 2016 Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, 2016. ²⁶Groisberg et al., J. Clin. Oncology, Vol. 34, Supp. Supplement 15, Abstract Number: 11046, 2016 Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, 2016. ²⁷Ihuegby et al., J. Clin. Oncology, Vol. 34, Supp. Supplement 15, Abstract Number: e20643, 2016 Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, 2016. ²⁸Tan et al., J. Clin. Oncology, Vol. 34, Supp. Supplement 15, Abstract Number: 9064, 2016 Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, 2016. ²⁹Wlodarska et al., Blood, Vol. 126(23):3654, 57th Annual Meeting of the American Society of Hematology, San Diego, CA, 2015. ³⁰Groisberg et al., Journal of Clinical Oncology, Vol. 34, Supp. Supplement 15; Abstract Number: 11046; 2016 Annual Meeting of the American Society of Clinical Oncology, ASCO 2016, Chicago, IL. 3-7 Jun. 2016. ³¹Vanden et al., Annals of Oncology, Vol. 27, Supp. Supplement 6. Abstract Number: 427PD' 41^(st) European Society for Medical Oncology Congress, ESMO 2016; Copenhagen, Denmark; 7-11 Oct. 2016. ³²Chmielecki et al., Cancer Research, 2017 Jan. 9. doi: 10.1158/0008-5472.CAN-16-1106. ³³Holla et al., Cold Spring Harb Mol Case Stud, 2017 January; 3(1):a001115. doi: 10.1101/mcs.a001115. ³⁴Yu et al., Oncotarget, 2016 Dec. 10. doi: 10.18632/oncotarget.13886. ³⁵Cui et al., Oncotarget. 2016 Dec. 1. doi: 10.18632/oncotarget.13741. ³⁶Panagopoulos et al., Modern Pathology 29: 1415-1423, 2016 ³⁷Li et al., J. Thorac. Oncol. 2017 January; 12(1):94-101. doi: 10.1016/j.jtho.2016.08.145. ³⁸European Patent Application Number EP2558490B1. ³⁹PCT Application No. WO2017001491A2. ⁴⁰Chmielecki et al., Cancer Research, Vol. 76, No. 14, Supp. Supplement. Abstract Number: LB-178. 107^(th) Annual meeting of the American Association for Cancer Research, AACR. New Orleans, LA. Apr. 16-20, 2016. ⁴¹Majweska et al., Cancer Research, Vol. 76, No. 14, Supp. Supplement. Abstract Number: 3190. 107^(th) Annual meeting of the American Association for Cancer Research, AACR. New Orleans, LA. Apr. 16-20, 2016.

In some embodiments, the dysregulation of an ALK gene, an ALK kinase, or expression or activity or level of any of the same, includes at least one point mutation in an ALK gene that results in the production of an ALK kinase that has one or more amino acid substitutions, insertions, or deletions as compared to the wild-type ALK kinase.

In some embodiments, an ALK-associated cancer has been identified as having one or more ALK inhibitor resistance mutations (that result in an increased resistance to an ALK inhibitor.

Tropomyosin-related kinase (TRK) is a receptor tyrosine kinase family of neurotrophin receptors that are found in multiple tissues types. Three members of the TRK proto-oncogene family have been described: TrkA, TrkB, and TrkC, encoded by the NTRK1, NTRK2, and NTRK3 genes, respectively. The TRK receptor family is involved in neuronal development, including the growth and function of neuronal synapses, memory development, and maintenance, and the protection of neurons after ischemia or other types of injury (Nakagawara, Cancer Lett. 169:107-114, 2001).

TRK was originally identified from a colorectal cancer cell line as an oncogene fusion containing 5′ sequences from tropomyosin-3 (TPM3) gene and the kinase domain encoded by the 3′ region of the neurotrophic tyrosine kinase, receptor, type 1 gene (NTRK1) (Pulciani et al., Nature 300:539-542, 1982; Martin-Zanca et al., Nature 319:743-748, 1986). TRK gene fusions follow the well-established paradigm of other oncogenic fusions, such as those involving ALK and ROS1, which have been shown to drive the growth of tumors and can be successfully inhibited in the clinic by targeted drugs (Shaw et al., New Engl. J. Med. 371:1963-1971, 2014; Shaw et al., New Engl. J. Med. 370:1189-1197, 2014). Oncogenic TRK fusions induce cancer cell proliferation and engage critical cancer-related downstream signaling pathways such as mitogen activated protein kinase (MAPK) and AKT (Vaishnavi et al., Cancer Discov. 5:25-34, 2015). Numerous oncogenic rearrangements involving NTRK1 and its related TRK family members NTRK2 and NTRK3 have been described (Vaishnavi et al., Cancer Disc. 5:25-34, 2015; Vaishnavi et al., Nature Med. 19:1469-1472, 2013). Although there are numerous different 5′ gene fusion partners identified, all share an in-frame, intact TRK kinase domain. A variety of different Trk inhibitors have been developed to treat cancer (see, e.g., U.S. Patent Application Publication No. 62/080,374, International Application Publication Nos. WO 11/006074, WO 11/146336, WO 10/033941, and WO 10/048314, and U.S. Pat. Nos. 8,933,084, 8,791,123, 8,637,516, 8,513,263, 8,450,322, 7,615,383, 7,384,632, 6,153,189, 6,027,927, 6,025,166, 5,910,574, 5,877,016, and 5,844,092).

The term “TRK-associated cancer” as used herein refers to cancers associated with or having a dysregulation of a TRK gene, a TRK protein, or expression or activity, or level of any of the same. Exemplary TRK-associated cancers are provided herein.

The phrase “dysregulation of a TRK gene, a TRK kinase, or the expression or activity or level of any of the same” refers to a genetic mutation (e.g., a TRK gene translocation that results in the expression of a fusion protein, a deletion in a TRK gene that results in the expression of a TRK protein that includes a deletion of at least one amino acid as compared to the wild-type TRK protein, a mutation in a TRK gene that results in the expression of a TRK protein with one or more point mutations, or an alternative spliced version of a TRK mRNA that results in a TRK protein having a deletion of at least one amino acid in the TRK protein as compared to the wild-type TRK protein) or a TRK gene amplification that results in overexpression of a TRK protein or an autocrine activity resulting from the overexpression of a TRK gene in a cell that results in a pathogenic increase in the activity of a kinase domain of a TRK protein (e.g., a constitutively active kinase domain of a TRK protein) in a cell. As another example, a dysregulation of a TRK gene, a TRK protein, or expression or activity, or level of any of the same, can be a mutation in a TRK gene that encodes a TRK protein that is constitutively active or has increased activity as compared to a protein encoded by a TRK gene that does not include the mutation. For example, a dysregulation of a TRK gene, a TRK protein, or expression or activity, or level of any of the same, can be the result of a gene or chromosome translocation which results in the expression of a fusion protein that contains a first portion of TRK that includes a functional kinase domain, and a second portion of a partner protein that is not TRK. In some examples, dysregulation of a TRK gene, a TRK protein, or expression or activity or level of any of the same can be a result of a gene translocation of one TRK gene with another non-TRK gene. Non-limiting examples of fusion proteins are described in Tables 6-8. Additional examples of TRK kinase protein mutations (e.g., point mutations) are TRK inhibitor resistance mutations.

The term “wildtype” or “wild-type” when referring to a TRK nucleic acid or protein describes a nucleic acid (e.g., a TRK gene or a TRK mRNA) or protein (e.g., a TRK protein) that is found in a subject that does not have a TRK-associated disease, e.g., a TRK-associated cancer (and optionally also does not have an increased risk of developing a TRK-associated disease and/or is not suspected of having a TRK-associated disease), or is found in a cell or tissue from a subject that does not have a TRK-associated disease, e.g., a TRK-associated cancer (and optionally also does not have an increased risk of developing a TRK-associated disease and/or is not suspected of having a TRK-associated disease).

In some embodiments, the dysregulation of a TRK gene, a TRK kinase protein, or expression or activity or level of any of the same, includes one or more chromosome translocations or inversions resulting in a TRK gene fusion. In some embodiments, the dysregulation of a TRK gene, a TRK kinase protein, or expression or activity or level of any of the same, is a result of genetic translocations in which the expressed protein is a fusion protein containing residues from a non-TRK partner protein, and includes a minimum of a functional TRK kinase domain. See, for example, Tables 6-8.

TABLE 6 Exemplary TrkA Fusion Proteins and Cancers Non-limiting Exemplary Trk-and Synonyms of Associated Fusion Protein Non-TrkA Fusion Partner Cancer(s) TP53-TrkA^(1,11) Tumor Protein P53 Spitzoid Melanoma, Spitz tumors LMNA-TrkA^(1,12) Lamin A/C Spitzoid Melanoma, Spitz tumors, Undifferentiated Sarcoma, Adult Soft Tissue Sarcoma (e.g., Soft Tissue Sarcoma Metastatic to Lung), Soft Tissue Fibrosarcoma, Spindle Cell Sarcoma^(G), Congenital Infantile Fibrosarcoma^(H), Pediatric haemangiopericytoma-like sarcoma^(I), Colorectal Cancer^(K) CD74-TrkA² MHC class II Non-Small Cell Lung invariant chain Cancer (NSCLC) Lung adenocarcimona TFG-TrkA TRK-Fused Gene Papillary Thyroid (TRK-T3)³ Carcinoma (PTC), Soft Tissue Solitary Fibrous Tumor TPM3-TrkA³ Tropomyosin 3 Lung Cancer, Papillary Thyroid Carcinoma (PTC), Acute Myeloid Leukemia (AML), Sarcoma, Pediatric Gliomas, Colorectal Cancer (CRC), Soft Tissue Schwannoma, Spitzoid melanocytic tumors^(J) NFASC-TrkA⁴ Neurofascin Gliobastoma multiforme (GBM); Glioblastoma BCAN-TrkA⁴ Brevican Glioblastoma multiforme (GBM) MPRIP-TrkA^(5,E) Myosin Phosphatase Non-small cell lung Rho Interacting cancer (NSCLC), Protein or Rho Lung adenocarcinoma Interacting Protein 3 TPR-TrkA Translocated Papillary Thyroid (TRK-T1 or Promoter Carcinoma (PTC), TRK-T2)³ Region, Nuclear Colorectal Cancer Basket (CRC)^(A), Non-small Protein cell lung cancer (NSCLC) RFWD2-TrkA⁶ Ring Finger and Large Cell WD Repeat Neuroendrocine Cancer Domain 2 (LCNEC); NSCLC IRF2BP2-TrkA⁷ Interferon Thyroid Cancer; Regulatory Factor Thyroid Gland 2 Binding Protein 2 Carcinoma SQSTM1-TrkA⁷ Sequestosome 1 Thyroid Cancer (e.g., Papillary Thyroid Cancer), Thyroid Gland Carcinoma, Soft TissueFibrosarcoma, Non-small- cell lung cancer^(L) SSBP2-TrkA⁷ Single-Stranded Thyroid Cancer DNA Binding (e.g., Papillary Protein 2 Thyroid Cancer); Thyroid Gland Carcinoma RABGAP1L- RAB GTPase Intrahepatic TrkA⁸ Activating Cholangicarcinoma Protein 1-Like (ICC) C180RF8-TrkA⁹ Chromosome Non-Small Cell 18 Open Lung Cancer Reading Frame 8 (NSCLC) RNF213-TrkA⁹ Ring Finger Non-Small Cell Protein 213 Lung Cancer (NSCLC) TBC1D22A- TBC1 Domain Family, Non-Small Cell TrkA⁹ Member 22A Lung Cancer (NSCLC) C200RF112- Chromosome Non-Small Cell TrkA⁹ 20 Open Lung Cancer Reading Frame 112 (NSCLC) DNER-TrkA⁹ Delta/Notch- Non-Small Cell Like EGF Lung Cancer Repeat Containing (NSCLC) ARHGEF2- Rho Guanine Nucleotide Glioblastoma TrkA¹³ Exchange Factor 2 CHTOP-TrkA¹³ Chromatin Target Glioblastoma of PRMT1 PPL-TrkA¹³ Periplakin Thyroid Carcinoma PLEKHA6-TrkA Pleckstrin Homology Domain-Containing Family A Member 6 PEAR1-TrkA Platelet Endothelial Aggregation Receptor 1 MRPL24-TrkA 39S Ribosomal Protein L24, Mitochondrial MDM4-TrkA Human Homolg of Mouse Double Minute 4 LRRC71-TrkA Leucine Rich Repeat Containing 71 GRIPAP1-TrkA GRIP1 Associated Protein 1 EPS15-TrkA Epidermal Growth Factor Receptor Substrate 15 DYNC2H1- Dynein, Cytoplasmic 2, Sarcoma TrkA^(B) Heavy Chain 1 CEL-TrkA Carboxyl Ester Lipase Pancreatic adenocarcinoma sample^(D) EPHB2-TrkA^(B) EPH Receptor B2 Lower Grade Glioma TGF-TrkA^(C) Transforming Growth Papillary Thyroid Cancer Factor NELL1-TrkA^(F) Cytoplasmic Protein Non-Small Cell That Contains Lung Cancer Epidermal Growth (NSCLC) Factor (Egf)-Like Repeats EPL4-TrkA^(F) EPH-Related Receptor Non-Small Cell Tyrosine Kinase Lung Cancer Ligand 4/ (NSCLC) Ephrin-A4 Protein CTNND2-TrkA^(F) Catenin (Cadherin- Non-Small Cell Associated Lung Cancer Protein), Delta 2 (NSCLC) TCEANC2- Transcription Non-Small Cell TrkA^(F) Elongation Factor A Lung Cancer (S11) N-Terminal (NSCLC) And Central Domain ^(A)Créancier et al., Cancer Lett. 365(1):107-111, 2015.J ^(B)U.S. Patent Application Publication No. 2015/0315657. ^(C)U.S. Patent Application Publication No. 2015/0283132. ^(D)Egren et al., Cancer Res. 75(15 Supplement): 4793, 2015. ^(E)U.S. Patent Application Publication No. 2015/0073036. ^(F)P.C.T. Patent Application Publication No. WO2015184443A1. ^(G)Haller et al., The Journal of pathology 238.5 (2016): 700-710. ^(H)Wong et al., J Natl Cancer Inst 2016; 108: djv307. ^(I)Haller et al., J. Pathol. 238(5): 700-10. ^(J)Gang et al., Mod Pathol. 2016 April; 29(4):359-69. ^(K)Konicek et al., Cancer research, Vol. 76, No. 14, Supp. Supplement. Abstract Number: 2647; 107^(th) Annual Meeting of the American Association for Cancer Research, AACR 2016. New Orleans, LA; 16-20 Apr. 2016. ^(L)Dtilon et al., Cancer research, Vol. 76, No. 14, Supp. Supplement. Abstract Number: CT007; 107^(th) Annual Meeting of the American Association for Cancer Research, AACR 2016. New Orleans, LA; 16-20 Apr. 2016.

TABLE 7 Exemplary TrkB Fusion Proteins and Cancers Non-limiting Exemplary Trk-and Synonyms of Associated Fusion Protein Non-TrkB Fusion Partner Cancer(s) NACC2-TrkB¹⁰ NACC Family Member 2, Pilocytic Astrocytoma BEN and BTB (POZ) Domain Containing QKI-TrkB¹⁰ QKI, KH Domain Pilocytic Astrocytoma Containing, RNA Binding AFAP1-TrkB⁷ Actin Filament Lower-grade Associated Glioma, In vitro Protein 1 (murine Ba/F3 cells)^(B), Pilocytic astrocytoma with anaplasia (PAA)^(E) PAN3-TrkB⁷ PAN3 Poly(A) Specific Head and Neck Squamous Cell Ribonuclease Subunit Carcinoma SQSTM1-TrkB⁷ Sequestosome 1 Lower-Grade Glioma TRIM24-TrkB⁷ Tripartite Motif Lung adenocarcinoma Containing 24 VCL-TrkB¹¹ Vinculin Pediatric gliomas AGBL4-TrkB¹¹ ATP/GTP Binding Pediatric gliomas Protein-Like 4 DAB2IP-TrkB Disabled Homolog 2- Interacting Protein NTRK2-TERT^(A) Telomerase Reverse Thyroid Cancer Transcriptase TEL-TrkB^(C) ETS Variant 6 In vitro (murine (ETV6) Ba/F3 cells) QKI-TrkB^(D) Protein Quaking Astrocytoma ^(A)PCT Patent Application Publication No. WO 2015/183836A1 ^(B)Drilon et al., Ann Oncol. 2016 May; 27(5):920-6. ^(C)Yuzugullu et al., Cell Discov. 2: 16030, 2016. ^(D)Ni et al., Neuro Oncol. 2017 January; 19(1):22-30. ^(E)Lin et al., Neuro-Oncol, Vol. 18, Supp. Supplement 3, pp. iii58, Abstract Number: HG-48; 17^(th) International Symposium on Pediatric Neuro-Oncology, ISPNO 2016. Liverpool, UK, 12 Jun. 2016-15 Jun. 2016.

TABLE 8 Exemplary TrkC Fusion Proteins and Cancers Non-limiting Exemplary Trk-and Synonyms of Associated Fusion Protein Non-TrkB Fusion Partner Cancer(s) ETV6-TrkC¹¹ ETS Variant 6 Salivary Gland (TEL; or Cancer, Secretory chromosomal Breast Carcinoma, translocation Acute Myeloid t(12; 15) Leukemia, Fibrosarcoma, (p13 ;q25))^(J) Nephroma, Melanoma, Colorectal Cancer (CRC), Breast Cancer, Pediatric Gliomas, Thyroid Cancer (e.g., Papillary Thyroid Cancer), Infantile Fibrosarcoma, Soft Tissue Hemangioma, Gastrointestinal Stromal Tumor (GIST) (e.g., c-kit-negative GIST), Mammary Carcinoma (e.g., Mammary Analogue Secretory Carcinoma, Secretory Breast Carcinoma (SBSC)^(K), Congenital Fibrosarcoma, Acute Myelogenous Leukemia, Polymorphous low-grade adenocarcinoma^(D), ALK-negative inflammatory myofibroblastic tumors (IMT)^(E), Infantile Fibrosarcoma (IFS)^(F), Acinic cell carcinoma (AcCC)^(G), Cellular mesoblastic nephroma^(H), Promyelocytic leukemia^(I), Burkitt Lymphoma^(I), B-cell lymphoma^(I), multiple myeloma^(I), medulloblastoma^(I), neuroblastoma^(I), ovarian cancer^(I), intestinal cancer^(I) BTBD1-TrkC¹¹ BTB (POZ) Domain Pediatric Gliomas Containing 1 LYN-TrkC⁷ V-Yes-1 Head and Neck Yamaguchi Sarcoma Squamous Cell Viral Related Carcinoma Oncogene Homolog (also known as Lck/Yes-Related Novel Protein Tyrosine Kinase) RBPMS-TrkC⁷ RNA Binding Thyroid Cancer Protein with (e.g., Papillary Multiple Splicing Thyroid Cancer) EML4-TrkC^(A) Echinoderm Fibrosarcoma Microtubule- (e.g., Pediatric Associated Fibrosarcoma^(L)) Protein-Like 4 HOMER2-TrkC Homer Protein Soft Tissue Sarcoma Homolog 2 TFG-TrkC TRK-Fused Gene Soft Tissue Solitary Fibrous Tumor FAT1-TrkC FAT Atypical Cervical Squamous Cell Cadherin 1 Carcinoma^(B) MYO5A-TrkC Myosin VA Spitz tumor^(C) MYH9-TrkC Myosin Heavy Chain 9 Spitz tumor^(C) ^(A)Tannenbaum et al., Cold Spring Harb. Mol. Case Stud. 1: a000471, 2015. ^(B)U.S. Patent Application Publication No. 2015/0315657. ^(C)Yeh et al., J Pathol. 240(3): 282-90, 2016 ^(D)Montalli et al., J Oral Pathol Med. doi: 10.1111/jop.12491, 2016 ^(E)Alassiri et al., Am J Surg Pathol. 2016 August; 40(8):1051-61. ^(F)Nagasubramanian et al., Pediatr Blood Cancer. 2016 August; 63(8):1468-70. ^(G)Chintakuntlawar et al., Oral Surg Oral Med Oral Pathol Oral Radiol. 2016 May; 121(5):542-549.e1. ^(H)U.S. Patent Application Publication No. US15030713A. ^(I)U.S Patent Application Publication No. US9447135B2. ^(J)Skalova et al., Modern Pathology 30, S27-S43, 2017. ^(K)Hyrcza et al., Vol. 469, Supp. Supplement 1, pp. S17. Abstract Number: OFP-1997-7; 31^(st) International Congress of the International Academy of Pathology and the 28^(th) Congress of the European Society of Pathology, Cologne, Germany. 25-29 Sep. 2016. ^(L)Sims et al., Journal of Immunotherapy of Cancer, Vol. 4, Supp. Supplement 1; Abstract Number: P280; 31^(st) Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer, SITC 2016. National Harbor, MD; 9-13 Nov. 2016.

In some embodiments, the dysregulation of a TRK gene, a TRK kinase, or expression or activity or level of any of the same, includes at least one point mutation in a TRK gene that results in the production of a TRK kinase that has one or more amino acid substitutions, insertions, or deletions as compared to the wild-type TRK kinase.

In some embodiments, a TRK-associated cancer has been identified as having one or more TRK inhibitor resistance mutations (that result in an increased resistance to a TRK inhibitor.

Accordingly, provided herein are methods for treating a patient diagnosed with (or identified as having) a cancer that include administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. Also provided herein are methods for treating a patient identified or diagnosed as having a ROS1-associated cancer that include administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof. In some embodiments, the patient that has been identified or diagnosed as having a ROS1-associated cancer through the use of a regulatory agency-approved, e.g., FDA-approved test or assay for identifying dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, in a patient or a biopsy sample from the patient or by performing any of the non-limiting examples of assays described herein. In some embodiments, the test or assay is provided as a kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the cancer is a ROS1-associated cancer. For example, the ROS1-associated cancer can be a cancer that includes one or more ROS1 inhibitor resistance mutations.

Also provided are methods for treating cancer in a patient in need thereof, the method comprising: (a) determining if the cancer in the patient is associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same; and (b) if the cancer is determined to be associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof. Some embodiments of these methods further include administering to the subject one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor). In some embodiments, one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor) are administered before a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor) are administered after a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor) are administered with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the subject was previously treated with a first ROS1 inhibitor or previously treated with another anticancer treatment, e.g., treatment with another anticancer agent, resection of the tumor or radiation therapy. In some embodiments, the subject was previously treated with an ALK inhibitor, a TRK inhibitor, or both. In some embodiments, the patient is determined to have a ROS1-associated cancer through the use of a regulatory agency-approved, e.g., FDA-approved test or assay for identifying dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, in a patient or a biopsy sample from the patient or by performing any of the non-limiting examples of assays described herein. In some embodiments, the test or assay is provided as a kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the cancer is a ROS1-associated cancer. For example, the ROS1-associated cancer can be a cancer that includes one or more ROS1 inhibitor resistance mutations.

Also provided are methods of treating a patient that include performing an assay on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, and administering (e.g., specifically or selectively administering) a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof to the patient determined to have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. Some embodiments of these methods further include administering to the subject one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor). In some embodiments, one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor) are administered before a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, one or more additional anticancer agents (e.g., a second ROS1 inhibitor (e.g., a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof), an ALK inhibitor, and/or a TRK inhibitor) are administered after a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, one or more additional anticancer agents (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor) are administered with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments of these methods, the subject was previously treated with a first ROS1 inhibitor or previously treated with another anticancer treatment, e.g., treatment with another anticancer agent, resection of a tumor or radiation therapy. In some embodiments, the subject was previously treated with an ALK inhibitor, a TRK inhibitor, or both. In some embodiments, the patient is a patient suspected of having a ROS1-associated cancer, a patient presenting with one or more symptoms of a ROS1-associated cancer, or a patient having an elevated risk of developing a ROS1-associated cancer. In some embodiments, the assay utilizes next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH). In some embodiments, the assay is a regulatory agency-approved assay, e.g., FDA-approved kit. In some embodiments, the assay is a liquid biopsy. Additional, non-limiting assays that may be used in these methods are described herein. Additional assays are also known in the art. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations.

Also provided is a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof for use in treating a ROS1-associated cancer in a patient identified or diagnosed as having a ROS1-associated cancer through a step of performing an assay (e.g., an in vitro assay) on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, where the presence of a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, identifies that the patient has a ROS1-associated cancer. Also provided is the use of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof for the manufacture of a medicament for treating a ROS1-associated cancer in a patient identified or diagnosed as having a ROS1-associated cancer through a step of performing an assay on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same where the presence of dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, identifies that the patient has a ROS1-associated cancer. Some embodiments of any of the methods or uses described herein further include recording in the patient's clinical record (e.g., a computer readable medium) that the patient is determined to have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, through the performance of the assay, should be administered a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof. In some embodiments, the assay utilizes next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH). In some embodiments, the assay is a regulatory agency-approved assay, e.g., FDA-approved kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations.

Also provided is a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of a cancer in a patient in need thereof or a patient identified or diagnosed as having a ROS1-associated cancer. Also provided is the use of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof for the manufacture of a medicament for treating a cancer in a patient identified or diagnosed as having a ROS1-associated cancer. In some embodiments, the cancer is a ROS1-associated cancer, for example, a ROS1-associated cancer having one or more ROS1 inhibitor resistance mutations. In some embodiments, a patient is identified or diagnosed as having a ROS1-associated cancer through the use of a regulatory agency-approved, e.g., FDA-approved, kit for identifying dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, in a patient or a biopsy sample from the sample. As provided herein, a ROS1-associated cancer includes those described herein and known in the art.

In some embodiments of any of the methods or uses described herein, the patient has been identified or diagnosed as having a cancer with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the patient has a tumor that is positive for a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the patient can be a patient with a tumor(s) that is positive for a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the patient can be a patient whose tumors have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the patient is suspected of having a ROS1-associated cancer (e.g., a cancer having one or more ROS1 inhibitor resistance mutations). In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a patient in need of such treatment, the method comprising a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the patient; and b) administering a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same includes one or more fusion proteins. Non-limiting examples of ROS1 gene fusion proteins are described in Table 2. In some embodiments, the fusion protein is SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same includes one or more ROS1 kinase protein point mutations, insertions, and/or deletions. Non-limiting examples of ROS1 kinase protein point mutations are described in Table 3 and Table 3a. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations. Non-limiting examples of ROS1 inhibitor resistance mutations are described in Table 4. In some embodiments, the ROS1 inhibitor resistance mutation is selected from the group consisting of L2026M, G2032R, and D2033N. In some embodiments, the cancer with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the tumor that is positive for a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is a tumor positive for one or more ROS1 inhibitor resistance mutations. In some embodiments, the tumor with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit. In some embodiments, the assay is a liquid biopsy.

In some embodiments of any of the methods or uses described herein, the patient has a clinical record indicating that the patient has a tumor that has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same (e.g., a tumor having one or more ROS1 inhibitor resistance mutations). In some embodiments, the clinical record indicates that the patient should be treated with one or more of the compounds of Formula I or a pharmaceutically acceptable salts or solvates thereof or compositions provided herein. In some embodiments, the cancer with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is a cancer having one or more ROS1 inhibitor resistance mutations. In some embodiments, the cancer with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the tumor that is positive for a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is a tumor positive for one or more ROS1 inhibitor resistance mutations. In some embodiments, the tumor with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same is determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit. In some embodiments, the assay is a liquid biopsy.

Also provided are methods of treating a patient that include administering a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof to a patient having a clinical record that indicates that the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. Also provided is the use of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof for the manufacture of a medicament for treating a ROS1-associated cancer in a patient having a clinical record that indicates that the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. Some embodiments of these methods and uses can further include: a step of performing an on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, and recording the information in a patient's clinical file (e.g., a computer readable medium) that the patient has been identified to have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. In some embodiments, the assay is an in vitro assay. For example, an assay that utilizes next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH). In some embodiments, the assay is a regulatory agency-approved, e.g., FDA-approved, kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the dysregulation of a ROS1 gene, ROS1 kinase, or expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations.

Also provided herein is a method of treating a subject. The method includes performing an assay on a sample obtained from the subject to determine whether the subject has a dysregulation of a ROS1 gene, a ROS1 protein, or expression or level of any of the same. The method also includes administering to a subject determined to have a dysregulation of a ROS1 gene, a ROS1 protein, or expression or activity, or level of any of the same a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the dysregulation in a ROS1 gene, a ROS1 kinase protein, or expression or activity of the same is a gene or chromosome translocation that results in the expression of a ROS1 fusion protein (e.g., any of the ROS1 fusion proteins described herein). In some embodiments, the ROS1 fusion can be selected from a SLC34A2 fusion, a CD74 fusion, a EZR fusion, a TPM3 fusion, or a SDC4 fusion. In some embodiments, the dysregulation in a ROS1 gene, a ROS1 kinase protein, or expression or activity or level of any of the same is one or more point mutation in the ROS1 gene (e.g., any of the one or more of the ROS1 point mutations described herein). The one or more point mutations in a ROS1 gene can result, e.g., in the translation of a ROS1 protein having one or more of the following amino acid substitutions: A15G, R118N, G1025R, T1735M, R1948H, and R2072N. In some embodiments, the dysregulation in a ROS1 gene, a ROS1 kinase protein, or expression or activity or level of any of the same is one or more ROS1 inhibitor resistance mutations (e.g., any combination of the one or more ROS1 inhibitor resistance mutations described herein). The one or more point mutations in a ROS1 gene can result, e.g., in the translation of a ROS1 protein having one or more of the following amino acid substitutions: L2026M, G2032R, and D2033N. Some embodiments of these methods further include administering to the subject another anticancer agent (e.g., a second ROS1 inhibitor, a second compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, an ALK inhibitor, and/or a TRK inhibitor).

Also provided are methods (e.g., in vitro methods) of selecting a treatment for a patient identified or diagnosed as having a ROS1-associated cancer. Some embodiments can further include administering the selected treatment to the patient identified or diagnosed as having a ROS1-associated cancer. For example, the selected treatment can include administration of a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. Some embodiments can further include a step of performing an assay on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, and identifying and diagnosing a patient determined to have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, as having a ROS1-associated cancer. In some embodiments, the cancer is a ROS1-associated cancer having one or more ROS1 inhibitor resistance mutations. In some embodiments, the patient has been identified or diagnosed as having a ROS1-associated cancer through the use of a regulatory agency-approved, e.g., FDA-approved, kit for identifying dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, in a patient or a biopsy sample from the patient. In some embodiments, the assay is a liquid biopsy. In some embodiments, the ROS1-associated cancers is a cancer described herein or known in the art. In some embodiments, the assay is an in vitro assay. For example, an assay that utilizes next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH). In some embodiments, the assay is a regulatory agency-approved, e.g., FDA-approved, kit. In some embodiments, the assay is a liquid biopsy.

Also provided herein are methods of selecting a treatment for a patient, wherein the methods include a step of performing an assay on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same (e.g., one or more ROS1 inhibitor resistance mutations), and identifying or diagnosing a patient determined to have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, as having a ROS1-associated cancer. Some embodiments further include administering the selected treatment to the patient identified or diagnosed as having a ROS1-associated cancer. For example, the selected treatment can include administration of a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof to the patient identified or diagnosed as having a ROS1-associated cancer. In some embodiments, the assay is an in vitro assay. For example, an assay that utilizes next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH). In some embodiments, the assay is a regulatory agency-approved, e.g., FDA-approved, kit. In some embodiments, the assay is a liquid biopsy.

Also provided are methods of selecting a patient for treatment, wherein the methods include selecting, identifying, or diagnosing a patient having a ROS1-associated cancer, and selecting the patient for treatment including administration of a therapeutically-effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, identifying or diagnosing a patient as having a ROS1-associated cancer can include a step of performing an assay on a sample obtained from the patient to determine whether the patient has a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, and identifying or diagnosing a patient determined to have a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same, as having a ROS1-associated cancer. In some embodiments, the method of selecting a treatment can be used as a part of a clinical study that includes administration of various treatments of a ROS1-associated cancer. In some embodiments, a ROS1-associated cancer is a cancer having one or more ROS1 inhibitor resistance mutations. In some embodiments, the assay is an in vitro assay. For example, an assay that utilizes next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH). In some embodiments, the assay is a regulatory agency-approved, e.g., FDA-approved, kit. In some embodiments, the assay is a liquid biopsy. In some embodiments, the dysregulation of the ROS1 gene, the ROS1 kinase, or expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations.

In some embodiments of any of the methods or uses described herein, an assay used to determine whether the patient has a dysregulation of a ROS1 gene, or a ROS1 kinase, or expression or activity or level of any of the same, using a sample from a patient can include, for example, next generation sequencing, pyrosequencing, immunohistochemistry, an enzyme-linked immunosorbent assay, and/or fluorescence in situ hybridization (FISH) (e.g., break apart FISH or dual-fusion FISH), fluorescence microscopy, Southern blotting, Western blotting, FACS analysis, Northern blotting, and PCR-based amplification (e.g., RT-PCR and quantitative real-time RT-PCR). As is well-known in the art, the assays are typically performed, e.g., with at least one labelled nucleic acid probe or at least one labelled antibody or antigen-binding fragment thereof. Assays can utilize other detection methods known in the art for detecting dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or levels of any of the same (see, e.g., the references cited herein). In some embodiments, the dysregulation of the ROS1 gene, the ROS1 kinase, or expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations. In some embodiments, the sample is a biological sample or a biopsy sample (e.g., a paraffin-embedded biopsy sample) from the patient. In some embodiments, the patient is a patient suspected of having a ROS1-associated cancer, a patient having one or more symptoms of a ROS1-associated cancer, and/or a patient that has an increased risk of developing a ROS1-associated cancer).

In some embodiments, dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same can be identified using a liquid biopsy (variously referred to as a fluid biopsy or fluid phase biopsy). See, e.g., Karachialiou et al., “Real-time liquid biopsies become a reality in cancer treatment”, Ann. Transl. Med., 3(3):36, 2016. Liquid biopsy methods can be used to detect total tumor burden and/or the dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same. Liquid biopsies can be performed on biological samples obtained relatively easily from a subject (e.g., via a simple blood draw) and are generally less invasive than traditional methods used to detect tumor burden and/or dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same. In some embodiments, liquid biopsies can be used to detect the presence of dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same at an earlier stage than traditional methods. In some embodiments, the biological sample to be used in a liquid biopsy can include, blood, plasma, urine, cerebrospinal fluid, saliva, sputum, broncho-alveolar lavage, bile, lymphatic fluid, cyst fluid, stool, ascites, and combinations thereof. In some embodiments, a liquid biopsy can be used to detect circulating tumor cells (CTCs). In some embodiments, a liquid biopsy can be used to detect cell-free DNA. In some embodiments, cell-free DNA detected using a liquid biopsy is circulating tumor DNA (ctDNA) that is derived from tumor cells. Analysis of ctDNA (e.g., using sensitive detection techniques such as, without limitation, next-generation sequencing (NGS), traditional PCR, digital PCR, or microarray analysis) can be used to identify dysregulation of a RET gene, a RET kinase, or the expression or activity or level of any of the same.

In some embodiments, ctDNA derived from a single gene can be detected using a liquid biopsy. In some embodiments, ctDNA derived from a plurality of genes (e.g., 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100 or more, or any number of genes in between these numbers) can be detected using a liquid biopsy. In some embodiments, ctDNA derived from a plurality of genes can be detected using any of a variety of commercially-available testing panels (e.g., commercially-available testing panels designed to detect dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same). Liquid biopsies can be used to detect dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same including, without limitation, point mutations or single nucleotide variants (SNVs), copy number variants (CNVs), genetic fusions (e.g., translocations or rearrangements), insertions, deletions, or any combination thereof. In some embodiments, a liquid biopsy can be used to detect a germline mutation. In some embodiments, a liquid biopsy can be used to detect a somatic mutation. In some embodiments, a liquid biopsy can be used to detect a primary genetic mutation (e.g., a primary mutation or a primary fusion that is associated with initial development of a disease, e.g., cancer). In some embodiments, a liquid biopsy can be used to detect a genetic mutation that develops after development of the primary genetic mutation (e.g., a resistance mutation that arises in response to a treatment administered to a subject). In some embodiments, a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same identified using a liquid biopsy is also present in a cancer cell that is present in the subject (e.g., in a tumor). In some embodiments, any of the types of dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same described herein can be detected using a liquid biopsy. In some embodiments, a genetic mutation identified via a liquid biopsy can be used to identify the subject as a candidate for a particular treatment. For example, detection of dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in the subject can indicate that the subject will be responsive to a treatment that includes administration of a compound of Formula I or a pharmaceutically acceptable salt thereof.

Liquid biopsies can be performed at multiple times during a course of diagnosis, a course of monitoring, and/or a course of treatment to determine one or more clinically relevant parameters including, without limitation, progression of the disease, efficacy of a treatment, or development of resistance mutations after administering a treatment to the subject. For example, a first liquid biopsy can be performed at a first time point and a second liquid biopsy can be performed at a second time point during a course of diagnosis, a course of monitoring, and/or a course of treatment. In some embodiments, the first time point can be a time point prior to diagnosing a subject with a disease (e.g., when the subject is healthy), and the second time point can be a time point after subject has developed the disease (e.g., the second time point can be used to diagnose the subject with the disease). In some embodiments, the first time point can be a time point prior to diagnosing a subject with a disease (e.g., when the subject is healthy), after which the subject is monitored, and the second time point can be a time point after monitoring the subject. In some embodiments, the first time point can be a time point after diagnosing a subject with a disease, after which a treatment is administered to the subject, and the second time point can be a time point after the treatment is administered; in such cases, the second time point can be used to assess the efficacy of the treatment (e.g., if the genetic mutation(s) detected at the first time point are reduced in abundance or are undetectable) or to determine the presence of a resistance mutation that has arisen as a result of the treatment. In some embodiments, a treatment to be administered to a subject can include a compound of Formula I or a pharmaceutically acceptable salt thereof.

In the field of medical oncology it is normal practice to use a combination of different forms of treatment to treat each patient with cancer. In medical oncology the other component(s) of such conjoint treatment or therapy in addition to compositions provided herein may be, for example, surgery, radiotherapy, and chemotherapeutic agents, such as kinase inhibitors, signal transduction inhibitors and/or monoclonal antibodies. Compounds of Formula I therefore may also be useful as adjuvants to cancer treatment, that is, they can be used in combination with one or more additional therapies or therapeutic agents, for example a chemotherapeutic agent that works by the same or by a different mechanism of action.

In some embodiments of any the methods described herein, the compound of Formula I (or a pharmaceutically acceptable salt or solvate thereof) is administered in combination with a therapeutically effective amount of at least one additional therapeutic agent selected from one or more additional therapies or therapeutic (e.g., chemotherapeutic) agents.

Non-limiting examples of additional therapeutic agents include: other ROS1-targeted therapeutic agents (i.e. a first or second ROS1 kinase inhibitor), ALK-targeted therapeutic agents (e.g., ALK kinase inhibitors), receptor tyrosine kinase-targeted therapeutic agents (e.g., TRK kinase inhibitors), kinase targeted therapeutics, signal transduction pathway inhibitors, checkpoint inhibitors, modulators of the apoptosis pathway (e.g. obataclax); cytotoxic chemotherapeutics, angiogenesis-targeted therapies, immune-targeted agents, including immunotherapy, and radiotherapy.

In some embodiments, the other ROS1-targeted therapeutic is a multikinase inhibitor exhibiting ROS1 inhibition activity. In some embodiments, the other ROS1-targeted therapeutic inhibitor is selective for a ROS1 kinase. Exemplary ROS1 kinase inhibitors can exhibit inhibition activity (IC₅₀) against a ROS1 kinase of less than about 1000 nM, less than about 500 nM, less than about 200 nM, less than about 100 nM, less than about 50 nM, less than about 25 nM, less than about 10 nM, or less than about 1 nM as measured in an assay as described herein. In some embodiments, a ROS1 kinase inhibitor can exhibit inhibition activity (IC₅₀) against a ROS1 kinase of less than about 25 nM, less than about 10 nM, less than about 5 nM, or less than about 1 nM as measured in an assay as provided herein.

Non-limiting examples of ROS1-targeted therapeutic agents include (E)-5-chloro-2-(2-(1-(4-fluorophenyl)ethylidene)hydrazinyl)-N-(2-(isopropylsulfonyl)phenyl)pyrimidin-4-amine (Eur. J. Org. Chem. 2016, 123, 80-89); alectinib; brigatinib; cabozantinib; ceritinib; crizotinib; entrectinib; foretinib; herbimycin A; lorlatinib; lorlatinib des-methyl analogs; merestinib; ASP3026 (NCT01284192; Astellas Pharma); AZD3634 (AstraZeneca); and ASP3026 (Astrellas Pharma).

In some embodiments, an ALK-targeted therapeutic is a multikinase inhibitor exhibiting ALK inhibition activity. In some embodiments, the ALK-targeted therapeutic inhibitor is selective for an ALK kinase. Exemplary ALK kinase inhibitors can exhibit inhibition activity (IC₅₀) against an ALK kinase of less than about 1000 nM, less than about 500 nM, less than about 200 nM, less than about 100 nM, less than about 50 nM, less than about 25 nM, less than about 10 nM, or less than about 1 nM as measured in an assay as described herein. In some embodiments, an ALK kinase inhibitor can exhibit inhibition activity (IC₅₀) against an ALK kinase of less than about 25 nM, less than about 10 nM, less than about 5 nM, or less than about 1 nM as measured in an assay.

Non-limiting examples of ALK-targeted therapeutic agents include “Amgen 36”; “Amgen 49”; “Cephalon 30”; “Chugai 13d”; 4-arylaminopyrimidine derivatives (see, e.g., Eur. J. Med. Chem. 2016, 123, 80-99); alectinib; anti-ALK monoclonal antibodies; brigatinib; ceritinib; crizotinib; dorsomorphin; ensartinib; entrectinib; ganetespib; lorlatinib; PF-02341066 (Pfizer); IPI-504 (Infinity); TSR-011 (Tesaro, Inc.); CT-707 (Centaurus Biopharma); AUY922; TEW-7197 (Medpacto); CEP-28122 (Teva Pharmaceuticals); CEP-37440 (Teva Pharmaceuticals); ASP3026 (Astellas Pharma); 17-AAG; IPI-504; GSK 1838705 (GlaxoSmithKline); KRCA 0008; AZD3463 (AstraZeneca); NVP-TAE684 (Novartis); “3-39” (Novartis); LDN193189; SB 525334; SB 505124; and TAE684.

In some embodiments, a receptor tyrosine kinase targeted therapeutic is a multikinase inhibitor (e.g., TRK-targeted therapeutic inhibitor) exhibiting TRK inhibition activity. In some embodiments, the TRK-targeted therapeutic inhibitor is selective for a TRK kinase. Exemplary TRK kinase inhibitors can exhibit inhibition activity (IC₅₀) against a TRK kinase of less than about 1000 nM, less than about 500 nM, less than about 200 nM, less than about 100 nM, less than about 50 nM, less than about 25 nM, less than about 10 nM, or less than about 1 nM as measured in an assay as described herein. In some embodiments, a TRK kinase inhibitor can exhibit inhibition activity (IC₅₀) against a TRK kinase of less than about 25 nM, less than about 10 nM, less than about 5 nM, or less than about 1 nM as measured in an assay. For example, a TRK inhibitor assay can be any of those provided in U.S. Pat. No. 8,933,084 (e.g., Example A or B).

Non-limiting examples of receptor tyrosine kinase (e.g., Trk) targeted therapeutic agents, include afatinib, cabozantinib, cetuximab, crizotinib, dabrafenib, entrectinib, erlotinib, gefitinib, imatinib, lapatinib, lestaurtinib, nilotinib, pazopanib, panitumumab, pertuzumab, sunitinib, trastuzumab, 1-((3S,4R)-4-(3-fluorophenyl)-1-(2-methoxyethyl)pyrrolidin-3-yl)-3-(4-methyl-3-(2-methylpyrimidin-5-yl)-1-phenyl-1H-pyrazol-5-yl)urea, AG 879, AR-772, AR-786, AR-256, AR-618, AZ-23, AZ623, DS-6051, Gö 6976, GNF-5837, GTx-186, GW 441756, LOXO-101, MGCD516, PLX7486, RXDX101, TPX-0005, and TSR-011. Additional Trk targeted therapeutic agents include those described in U.S. Pat. Nos. 8,450,322; 8,513,263; 8,933,084; 8,791,123; 8,946,226; 8,450,322; 8,299,057; and 8,912,194; U.S. Publication No. 2016/0137654; 2015/0166564; 2015/0051222; 2015/0283132; and 2015/0306086; International Publication No. WO 2010/033941; WO 2010/048314; WO 2016/077841; WO 2011/146336; WO 2011/006074; WO 2010/033941; WO 2012/158413; WO 2014078454; WO 2014078417; WO 2014078408; WO 2014078378; WO 2014078372; WO 2014078331; WO 2014078328; WO 2014078325; WO 2014078323; WO 2014078322; WO 2015175788; WO 2009/013126; WO 2013/174876; WO 2015/124697; WO 2010/058006; WO 2015/017533; WO 2015/112806; WO 2013/183578; and WO 2013/074518, all of which are hereby incorporated by reference in their entireties.

Further examples of Trk inhibitors can be found in U.S. Pat. No. 8,637,516, International Publication No. WO 2012/034091, U.S. Pat. No. 9,102,671, International Publication No. WO 2012/116217, U.S. Publication No. 2010/0297115, International Publication No. WO 2009/053442, U.S. Pat. No. 8,642,035, International Publication No. WO 2009092049, U.S. Pat. No. 8,691,221, International Publication No. WO2006131952, all of which are incorporated by reference in their entireties herein. Exemplary Trk inhibitors include GNF-4256, described in Cancer Chemother. Pharmacol. 75(1):131-141, 2015; and GNF-5837 (N-[3-[[2,3-dihydro-2-oxo-3-(1H-pyrrol-2-ylmethylene)-1H-indol-6-yl]amino]-4-methylphenyl]-N′-[2-fluoro-5-(trifluoromethyl)phenyl]-urea), described in ACS Med. Chem. Lett. 3(2):140-145, 2012, each of which is incorporated by reference in its entirety herein.

Additional examples of Trk inhibitors include those disclosed in U.S. Publication No. 2010/0152219, U.S. Pat. No. 8,114,989, and International Publication No. WO 2006/123113, all of which are incorporated by reference in their entireties herein. Exemplary Trk inhibitors include AZ623, described in Cancer 117(6):1321-1391, 2011; AZD6918, described in Cancer Biol. Ther. 16(3):477-483, 2015; AZ64, described in Cancer Chemother. Pharmacol. 70:477-486, 2012; AZ-23 ((S)-5-Chloro-N2-(1-(5-fluoropyridin-2-yl)ethyl)-N4-(5 sopropoxy-1H-pyrazol-3-yl)pyrimidine-2,4-diamine), described in Mol. Cancer Ther. 8:1818-1827, 2009; and AZD7451; each of which is incorporated by reference in its entirety.

A Trk inhibitor can include those described in U.S. Pat. Nos. 7,615,383; 7,384,632; 6,153,189; 6,027,927; 6,025,166; 5,910,574; 5,877,016; and 5,844,092, each of which is incorporated by reference in its entirety.

Further examples of Trk inhibitors include CEP-751, described in Int. J. Cancer 72:672-679, 1997; CT327, described in Acta Derm. Venereol. 95:542-548, 2015; compounds described in International Publication No. WO 2012/034095; compounds described in U.S. Pat. No. 8,673,347 and International Publication No. WO 2007/022999; compounds described in U.S. Pat. No. 8,338,417; compounds described in International Publication No. WO 2016/027754; compounds described in U.S. Pat. No. 9,242,977; compounds described in U.S. Publication No. 2016/0000783; sunitinib (N-(2-diethylaminoethyl)-5-[(Z)-(5-fluoro-2-oxo-1H-indol-3-ylidene)methyl]-2,4-dimethyl-1H-pyrrole-3-carboxamide), as described in PLoS One 9:e95628, 2014; compounds described in International Publication No. WO 2011/133637; compounds described in U.S. Pat. No. 8,637,256; compounds described in Expert. Opin. Ther. Pat. 24(7):731-744, 2014; compounds described in Expert Opin. Ther. Pat. 19(3):305-319, 2009; (R)-2-phenylpyrrolidine substituted imidazopyridazines, e.g., GNF-8625, (R)-1-(6-(6-(2-(3-fluorophenyl)pyrrolidin-1-yl)imidazo[1,2-b]pyridazin-3-yl)-[2,4′-bipyridin]-2′-yl)piperidin-4-ol as described in ACS Med. Chem. Lett. 6(5):562-567, 2015; GTx-186 and others, as described in PLoS One 8(12):e83380, 2013; K252a ((9S-(9α,10β,12α))-2,3,9,10,11,12-hexahydro-10-hydroxy-10-(methoxycarbonyl)-9-methyl-9,12-epoxy-1H-diindolo[1,2,3-fg:3′,2′,1′-kl]pyrrolo[3,4-i][1,6]benzodiazocin-1-one), as described in Mol. Cell Biochem. 339(1-2):201-213, 2010; 4-aminopyrazolylpyrimidines, e.g., AZ-23 (((S)-5-chloro-N2-(1-(5-fluoropyridin-2-yl)ethyl)-N4-(5-isopropoxy-1H-pyrazol-3-yl)pyrimidine-2,4-diamine)), as described in J. Med. Chem. 51(15):4672-4684, 2008; PHA-739358 (danusertib), as described in Mol. Cancer Ther. 6:3158, 2007; Gö 6976 (5,6,7,13-tetrahydro-13-methyl-5-oxo-12H-indolo[2,3-a]pyrrolo[3,4-c]carbazole-12-propanenitrile), as described in J. Neurochem. 72:919-924, 1999; GW441756 ((3Z)-3-[(1-methylindol-3-yl)methylidene]-1H-pyrrolo[3,2-b]pyridin-2-one), as described in IJAE 115:117, 2010; milciclib (PHA-848125AC), described in J. Carcinog. 12:22, 2013; AG-879 ((2E)-3-[3,5-Bis(1,1-dimethylethyl)-4-hydroxyphenyl]-2-cyano-2-propenethioamide); altiratinib (N-(4-((2-(cyclopropanecarboxamido)pyridin-4-yl)oxy)-2,5-difluorophenyl)-N-(4-fluorophenyl)cyclopropane-1,1-dicarboxamide); cabozantinib (N-(4-((6,7-Dimethoxyquinolin-4-yl)oxy)phenyl)-N′-(4-fluorophenyl)cyclopropane-1,1-dicarboxamide); lestaurtinib ((5S,6S,8R)-6-Hydroxy-6-(hydroxymethyl)-5-methyl-7,8,14,15-tetrahydro-5H-16-oxa-4b,8a,14-triaza-5,8-methanodibenzo[b,h]cycloocta[jkl]cyclopenta[e]-as-indacen-13(6H)-one); dovatinib (4-amino-5-fluoro-3-[6-(4-methylpiperazin-1-yl)-1H-benzimidazol-2-yl]quinolin-2(1H)-one mono 2-hydroxypropanoate hydrate); sitravatinib (N-(3-fluoro-4-((2-(5-(((2-methoxyethyl)amino)methyl)pyridin-2-yl)thieno[3,2-b]pyridin-7-yl)oxy)phenyl)-N-(4-fluorophenyl)cyclopropane-1,1-dicarboxamide); ONO-5390556; regorafenib (4-[4-({[4-Chloro-3-(trifluoromethyl)phenyl]carbamoyl}amino)-3-fluorophenoxy]-N-methylpyridine-2-carboxamide hydrate); and VSR-902A; all of the references above are incorporated by reference in their entireties herein.

The ability of a Trk inhibitor to act as a TrkA, TrkB, and/or Trk C inhibitor may be tested using the assays described in Examples A and B in U.S. Pat. No. 8,513,263, which is incorporated herein by reference.

In some embodiments, signal transduction pathway inhibitors include Ras-Raf-MEK-ERK pathway inhibitors (e.g., binimetinib, selumetinib, encorafinib, sorafenib, trametinib, and vemurafenib), PI3K-Akt-mTOR-S6K pathway inhibitors (e.g. everolimus, rapamycin, perifosine, temsirolimus), and other kinase inhibitors, such as baricitinib, brigatinib, capmatinib, danusertib, ibrutinib, milciclib, quercetin, regorafenib, ruxolitinib, semaxanib, AP32788, BLU285, BLU554, INCB39110, INCB40093, INCB50465, INCB52793, INCB54828, MGCD265, NMS-088, NMS-1286937, PF 477736 ((R)-amino-N-[5,6-dihydro-2-(1-methyl-1H-pyrazol-4-yl)-6-oxo-1Hpyrrolo[4,3,2-ef][2,3]benzodiazepin-8-yl]-cyclohexaneacetamide), PLX3397, PLX7486, PLX8394, PLX9486, PRN1008, PRN1371, RXDX103, RXDX106, RXDX108, and TG101209 (N-tert-butyl-3-(5-methyl-2-(4-(4-methylpiperazin-1-yl)phenylamino)pyrimidin-4-ylamino)benzenesulfonamide).

Non-limiting examples of checkpoint inhibitors include ipilimumab, tremelimumab, nivolumab, pidilizumab, MPDL3208A, MEDI4736, MSB0010718C, BMS-936559, BMS-956559, BMS-935559 (MDX-1105), AMP-224, and pembrolizumab.

In some embodiments, cytotoxic chemotherapeutics are selected from arsenic trioxide, bleomycin, cabazitaxel, capecitabine, carboplatin, cisplatin, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, docetaxel, doxorubicin, etoposide, fluorouracil, gemcitabine, irinotecan, lomustine, methotrexate, mitomycin C, oxaliplatin, paclitaxel, pemetrexed, temozolomide, and vincristine.

Non-limiting examples of angiogenesis-targeted therapies include aflibercept and bevacizumab.

The term “immunotherapy” refers to an agent that modulates the immune system. In some embodiments, an immunotherapy can increase the expression and/or activity of a regulator of the immune system. In some embodiments, an immunotherapy can decrease the expression and/or activity of a regulator of the immune system. In some embodiments, an immunotherapy can recruit and/or enhance the activity of an immune cell.

In some embodiments, the immunotherapy is a cellular immunotherapy (e.g., adoptive T-cell therapy, dendritic cell therapy, natural killer cell therapy). In some embodiments, the cellular immunotherapy is sipuleucel-T (APC8015; Provenge™; Plosker (2011) Drugs 71(1): 101-108). In some embodiments, the cellular immunotherapy includes cells that express a chimeric antigen receptor (CAR). In some embodiments, the cellular immunotherapy is a CAR-T cell therapy. In some embodiments, the CAR-T cell therapy is tisagenlecleucel (Kymriah™).

In some embodiments, the immunotherapy is an antibody therapy (e.g., a monoclonal antibody, a conjugated antibody). In some embodiments, the antibody therapy is bevacizumab (Mvasti™, Avastin®), trastuzumab (Herceptin®), avelumab (Bavencio®), rituximab (MabThera™, Rituxan®), edrecolomab (Panorex), daratumuab (Darzalex®), olaratumab (Lartruvo™), ofatumumab (Arzerra®), alemtuzumab (Campath®), cetuximab (Erbitux®), oregovomab, pembrolizumab (Keytruda®), dinutiximab (Unituxin®), obinutuzumab (Gazyva®), tremelimumab (CP-675,206), ramucirumab (Cyramza®), ublituximab (TG-1101), panitumumab (Vectibix®), elotuzumab (Empliciti™), avelumab (Bavencio®), necitumumab (Portrazza™), cirmtuzumab (UC-961), ibritumomab (Zevalin®), isatuximab (SAR650984), nimotuzumab, fresolimumab (GC1008), lirilumab (INN), mogamulizumab (Poteligeo®), ficlatuzumab (AV-299), denosumab (Xgeva®), ganitumab, urelumab, pidilizumab or amatuximab.

In some embodiments, the immunotherapy is an antibody-drug conjugate. In some embodiments, the antibody-drug conjugate is gemtuzumab ozogamicin (Mylotarg™), inotuzumab ozogamicin (Besponsa®), brentuximab vedotin (Adcetris®), ado-trastuzumab emtansine (TDM-1; Kadcyla®), mirvetuximab soravtansine (IMGN853) or anetumab ravtansine

In some embodiments, the immunotherapy includes blinatumomab (AMG103; Blincyto®) or midostaurin (Rydapt).

In some embodiments, the immunotherapy includes a toxin. In some embodiments, the immunotherapy is denileukin diftitox (Ontak®).

In some embodiments, the immunotherapy is a cytokine therapy. In some embodiments, the cytokine therapy is an interleukin 2 (IL-2) therapy, an interferon alpha (IFNα) therapy, a granulocyte colony stimulating factor (G-CSF) therapy, an interleukin 12 (IL-12) therapy, an interleukin 15 (IL-15) therapy, an interleukin 7 (IL-7) therapy or an erythropoietin-alpha (EPO) therapy. In some embodiments, the IL-2 therapy is aldesleukin (Proleukin®). In some embodiments, the IFNα therapy is IntronA® (Roferon-A®). In some embodiments, the G-CSF therapy is filgrastim (Neupogen®).

In some embodiments, the immunotherapy is an immune checkpoint inhibitor. In some embodiments, the immunotherapy includes one or more immune checkpoint inhibitors. In some embodiments, the immune checkpoint inhibitor is a CTLA-4 inhibitor, a PD-1 inhibitor or a PD-L1 inhibitor. In some embodiments, the CTLA-4 inhibitor is ipilimumab (Yervoy®) or tremelimumab (CP-675,206). In some embodiments, the PD-1 inhibitor is pembrolizumab (Keytruda®) or nivolumab (Opdivo®). In some embodiments, the PD-L1 inhibitor is atezolizumab (Tecentriq®), avelumab (Bavencio®) or durvalumab (Imfinzi™).

In some embodiments, the immunotherapy is mRNA-based immunotherapy. In some embodiments, the mRNA-based immunotherapy is CV9104 (see, e.g., Rausch et al. (2014) Human Vaccin Immunother 10(11): 3146-52; and Kubler et al. (2015) J. Immunother Cancer 3:26).

In some embodiments, the immunotherapy is bacillus Calmette-Guerin (BCG) therapy.

In some embodiments, the immunotherapy is an oncolytic virus therapy. In some embodiments, the oncolytic virus therapy is talimogene alherparepvec (T-VEC; Imlygic®).

In some embodiments, the immunotherapy is a cancer vaccine. In some embodiments, the cancer vaccine is a human papillomavirus (HPV) vaccine. In some embodiments, the HPV vaccine is Gardasil®, Gardasil9® or Cervarix®. In some embodiments, the cancer vaccine is a hepatitis B virus (HBV) vaccine. In some embodiments, the HBV vaccine is Engerix-B®, Recombivax HB® or GI-13020 (Tarmogen®). In some embodiments, the cancer vaccine is Twinrix® or Pediarix®. In some embodiments, the cancer vaccine is BiovaxID®, Oncophage®, GVAX, ADXS11-001, ALVAC-CEA, PROSTVAC®, Rindopepimut®, CimaVax-EGF, lapuleucel-T (APC8024; Neuvenge™), GRNVAC1, GRNVAC2, GRN-1201, hepcortespenlisimut-L (Hepko-V5), DCVAX®, SCIB1, BMT CTN 1401, PrCa VBIR, PANVAC, ProstAtak®, DPX-Survivac, or viagenpumatucel-L (HS-110).

In some embodiments, the immunotherapy is a peptide vaccine. In some embodiments, the peptide vaccine is nelipepimut-S (E75) (NeuVax™), IMA901, or SurVaxM (SVN53-67). In some embodiments, the cancer vaccine is an immunogenic personal neoantigen vaccine (see, e.g., Ott et al. (2017) Nature 547: 217-221; Sahin et al. (2017) Nature 547: 222-226). In some embodiments, the cancer vaccine is RGSH4K, or NEO-PV-01. In some embodiments, the cancer vaccine is a DNA-based vaccine. In some embodiments, the DNA-based vaccine is a mammaglobin-A DNA vaccine (see, e.g., Kim et al. (2016) OncoImmunology 5(2): e1069940).

In some embodiments, immune-targeted agents are selected from aldesleukin, interferon alfa-2b, ipilimumab, lambrolizumab, nivolumab, prednisone, and sipuleucel-T.

Non-limiting examples of radiotherapy include radioiodide therapy, external-beam radiation, and radium 223 therapy.

Additional kinase inhibitors include those described in, for example, U.S. Pat. Nos. 7,514,446; 7,863,289; 8,026,247; 8,501,756; 8,552,002; 8,815,901; 8,912,204; 9,260,437; 9,273,051; U.S. Publication No. US 2015/0018336; International Publication No. WO 2007/002325; WO 2007/002433; WO 2008/080001; WO 2008/079906; WO 2008/079903; WO 2008/079909; WO 2008/080015; WO 2009/007748; WO 2009/012283; WO 2009/143018; WO 2009/143024; WO 2009/014637; 2009/152083; WO 2010/111527; WO 2012/109075; WO 2014/194127; WO 2015/112806; WO 2007/110344; WO 2009/071480; WO 2009/118411; WO 2010/031816; WO 2010/145998; WO 2011/092120; WO 2012/101032; WO 2012/139930; WO 2012/143248; WO 2012/152763; WO 2013/014039; WO 2013/102059; WO 2013/050448; WO 2013/050446; WO 2014/019908; WO 2014/072220; WO 2014/184069; and WO 2016/075224, all of which are hereby incorporated by reference in their entireties.

Further examples of kinase inhibitors include those described in, for example, WO 2016/081450; WO 2016/022569; WO 2016/011141; WO 2016/011144; WO 2016/011147; WO 2015/191667; WO 2012/101029; WO 2012/113774; WO 2015/191666; WO 2015/161277; WO 2015/161274; WO 2015/108992; WO 2015/061572; WO 2015/058129; WO 2015/057873; WO 2015/017528; WO/2015/017533; WO 2014/160521; and WO 2014/011900, each of which is hereby incorporated by reference in its entirety.

In some embodiments, a kinase inhibitor as provided herein may have activity against more than one kinase (i.e. may be a multikinase inhibitor). When more than one mechanism of action is recited in a method herein (e.g., ROS1, ALK, or TRK kinase inhibition), each of the compounds recited are structurally distinct from one another (e.g., the ROS1 inhibitor and the TRK inhibitor are not the same compound).

Accordingly, also provided herein is a method of treating cancer, comprising administering to a patient in need thereof a pharmaceutical combination for treating cancer which comprises (a) a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, (b) an additional therapeutic agent, and (c) optionally at least one pharmaceutically acceptable carrier for simultaneous, separate or sequential use for the treatment of cancer, wherein the amounts of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof and the additional therapeutic agent are together effective in treating the cancer.

These additional therapeutic agents may be administered with one or more doses of the compound of Formula I, or a pharmaceutically acceptable salt or solvate thereof, or pharmaceutical composition thereof, as part of the same or separate dosage forms, via the same or different routes of administration, and/or on the same or different administration schedules according to standard pharmaceutical practice known to one skilled in the art.

Also provided herein is (i) a pharmaceutical combination for treating a cancer in a patient in need thereof, which comprises (a) a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, (b) at least one additional therapeutic agent (e.g., any of the exemplary additional therapeutic agents described herein or known in the art), and (c) optionally at least one pharmaceutically acceptable carrier for simultaneous, separate or sequential use for the treatment of cancer, wherein the amounts of the compound of Formula I or pharmaceutically acceptable salt or solvate thereof and of the additional therapeutic agent are together effective in treating the cancer; (ii) a pharmaceutical composition comprising such a combination; (iii) the use of such a combination for the preparation of a medicament for the treatment of cancer; and (iv) a commercial package or product comprising such a combination as a combined preparation for simultaneous, separate or sequential use; and to a method of treatment of cancer in a patient in need thereof. In some embodiments the patient is a human. In some embodiments, the cancer is a ROS1-associated cancer, e.g., a ROS1-associated cancer having one or more ROS1 inhibitor resistance mutations.

The term “pharmaceutical combination”, as used herein, refers to a pharmaceutical therapy resulting from the mixing or combining of more than one active ingredient and includes both fixed and non-fixed combinations of the active ingredients. The term “fixed combination” means that a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof and at least one additional therapeutic agent (e.g., a chemotherapeutic agent), are both administered to a patient simultaneously in the form of a single composition or dosage. The term “non-fixed combination” means that a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof and at least one additional therapeutic agent (e.g., chemotherapeutic agent) are formulated as separate compositions or dosages such that they may be administered to a patient in need thereof simultaneously, concurrently or sequentially with variable intervening time limits (e.g., 1 hour, 1 day, 1 week, 2 weeks, 3 weeks, 1 month, 2 months, 3 months), wherein such administration provides effective levels of the two or more compounds in the body of the patient. These also apply to cocktail therapies, e.g. the administration of three or more active ingredients

Accordingly, also provided herein is a method of treating a cancer, comprising administering to a patient in need thereof a pharmaceutical combination for treating cancer which comprises (a) a compound of Formula I or pharmaceutically acceptable salt or solvate thereof, (b) an additional therapeutic agent, and (c) optionally at least one pharmaceutically acceptable carrier for simultaneous, separate or sequential use for the treatment of cancer, wherein the amounts of the compound of Formula I or pharmaceutically acceptable salt or solvate thereof and the additional therapeutic agent are together effective in treating the cancer. In some embodiments, the compound of Formula I or pharmaceutically acceptable salt or solvate thereof, and the additional therapeutic agent are administered simultaneously as separate dosages. In some embodiments, the compound of Formula I or pharmaceutically acceptable salt or solvate thereof, and the additional therapeutic agent are administered as separate dosages sequentially in any order, in jointly therapeutically effective amounts, e.g. in daily or intermittently dosages. In some embodiments, the compound of Formula I or pharmaceutically acceptable salt or solvate thereof, and the additional therapeutic agent are administered simultaneously as a combined dosage. In some embodiments, the cancer is a ROS1-associated cancer. For example, a ROS1-associated cancer having one or more ROS1 inhibitor resistance mutations.

Also provided herein is a method of treating a disease or disorder mediated by ROS1 in a patient in need of such treatment, the method comprising administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof. In some embodiments, the disease or disorder mediated by ROS1 is a dysregulation of ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same. For example, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same includes one or more ROS1 inhibitor resistance mutations. A disease or disorder mediated by ROS1 can include any disease, disorder or condition that is directly or indirectly linked to expression or activity of ROS1, including overexpression and/or abnormal activity levels. In some embodiments, the disease is cancer (e.g., a ROS1-associated cancer). In some embodiments, the cancer is any of the cancers or ROS1-associated cancers described herein.

Although the genetic basis of tumorigenesis may vary between different cancer types, the cellular and molecular mechanisms required for metastasis appear to be similar for all solid tumor types. During a metastatic cascade, the cancer cells lose growth inhibitory responses, undergo alterations in adhesiveness and produce enzymes that can degrade extracellular matrix components. This leads to detachment of tumor cells from the original tumor, infiltration into the circulation through newly formed vasculature, migration and extravasation of the tumor cells at favorable distant sites where they may form colonies. A number of genes have been identified as being promoters or suppressors of metastasis.

Accordingly, also provided herein are methods for inhibiting, preventing, aiding in the prevention, or decreasing the symptoms of metastasis of a cancer in a patient in need thereof, the method comprising administering to the patient a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition thereof. Such methods can be used in the treatment of one or more of the cancers described herein. See, e.g., US Publication No. 2013/0029925; International Publication No. WO 2014/083567; and U.S. Pat. No. 8,568,998. In some embodiments, the cancer is a ROS1-associated cancer. In some embodiments, the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof is used in combination with an additional therapy or another therapeutic agent, including a chemotherapeutic agent, such as a kinase inhibitor, for example, a first or second ROS1 kinase inhibitor.

The term “metastasis” is an art known term and means the formation of an additional tumor (e.g., a solid tumor) at a site distant from a primary tumor in a subject or patient, where the additional tumor includes the same or similar cancer cells as the primary tumor.

Also provided are methods of decreasing the risk of developing a metastasis or an additional metastasis in a patient having a ROS1-associated cancer that include: selecting, identifying, or diagnosing a patient as having a ROS1-associated cancer, and administering a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof to the patient selected, identified, or diagnosed as having a ROS1-associated cancer. Also provided are methods of decreasing the risk of developing a metastasis or an additional metastasis in a patient having a ROS1-associated cancer that includes administering a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvent thereof to a patient having a ROS1-associated cancer. The decrease in the risk of developing a metastasis or an additional metastasis in a patient having a ROS1-associated cancer can be compared to the risk of developing a metastasis or an additional metastasis in the patient prior to treatment, or as compared to a patient or a population of patients having a similar or the same ROS1-associated cancer that has received no treatment or a different treatment. In some embodiments, the ROS1-associated cancer is a ROS1-associated cancer having one or more ROS1 inhibitor resistance mutations.

The phrase “risk of developing a metastasis” means the risk that a subject or patient having a primary tumor will develop an additional tumor (e.g., a solid tumor) at a site distant from a primary tumor in a subject or patient over a set period of time, where the additional tumor includes the same or similar cancer cells as the primary tumor. Methods for reducing the risk of developing a metastasis in a subject or patient having a cancer are described herein.

The phrase “risk of developing additional metastases” means the risk that a subject or patient having a primary tumor and one or more additional tumors at sites distant from the primary tumor (where the one or more additional tumors include the same or similar cancer cells as the primary tumor) will develop one or more further tumors distant from the primary tumor, where the further tumors include the same or similar cancer cells as the primary tumor. Methods for reducing the risk of developing additional metastasis are described herein.

In some embodiments, the presence of one or more ROS1 inhibitor resistance mutations in a tumor causes the tumor to be more resistant to treatment with a first ROS1 inhibitor. Methods useful when a ROS1 inhibitor resistance mutation causes the tumor to be more resistant to treatment with a first ROS1 inhibitor are described below. For example, provided herein are methods of treating a subject having a cancer that include: identifying a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations; and administering to the identified subject a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof is administered in combination with the first ROS1 inhibitor. Also provided are methods of treating a subject identified as having a cancer cell that has one or more ROS1 inhibitor resistance mutations that include administering to the subject a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof is administered in combination with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N.

For example, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a compound of Formula I, or a pharmaceutically acceptable salt of solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more fusion proteins of Table 2 and/or one or more ROS1 kinase protein point mutations, insertions, and/or deletions (e.g., one or more point mutations of Table 3 or Table 3a) in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations of Table 4; and (d) administering a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more of the fusion proteins SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1 in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more of the ROS1 inhibitor resistance mutations L2026M, G2032R, or D2033N; and (d) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof selected from the group consisting of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations.

For example, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor, wherein the first ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a compound of Formula I, or a pharmaceutically acceptable salt of solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor, wherein the first ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more fusion proteins of Table 2 and/or one or more ROS1 kinase protein point mutations, insertions, and/or deletions (e.g., one or more point mutations of Table 3 or Table 3a) in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor, wherein the first ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations of Table 4; and (d) administering a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more of the fusion proteins SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1 in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a first ROS1 inhibitor, wherein the first ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more of the ROS1 inhibitor resistance mutations L2026M, G2032R, or D2033N; and (d) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof selected from the group consisting of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the first ROS1 inhibitor of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations.

As another example, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I, or a pharmaceutically acceptable salt of solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a second ROS1 inhibitor, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a second ROS1 inhibitor, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more fusion proteins of Table 2 and/or one or more ROS1 kinase protein point mutations, insertions, and/or deletions (e.g., one or more of the point mutations of Table 3 or Table 3a) in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations of Table 4; and (d) administering a second ROS1 inhibitor, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more of the fusion proteins SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1 in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more of the ROS1 inhibitor resistance mutations L2026M, G2032R, or D2033N; and (d) administering a second ROS1 inhibitor, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations.

In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I, or a pharmaceutically acceptable salt of solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a second ROS1 inhibitor, wherein the second ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering a second ROS1 inhibitor, wherein the second ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more fusion proteins of Table 2 and/or one or more ROS1 kinase protein point mutations, insertions, and/or deletions (e.g., one or more of the point mutations of Table 3 or Table 3a) in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations of Table 4; and (d) administering a second ROS1 inhibitor, wherein the second ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more of the fusion proteins SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1 in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more of the ROS1 inhibitor resistance mutations L2026M, G2032R, or D2033N; and (d) administering a second ROS1 inhibitor, wherein the second ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib, as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (e) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations.

Also, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject as a monotherapy or in conjunction with another anticancer agent (e.g., a second ROS1 inhibitor, a second compound of Formula I, an ALK inhibitor, a TRK inhibitor, or a pharmaceutically acceptable salt thereof) or anticancer therapy (e.g., surgery or radiation) if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations. In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting a dysregulation of a ROS1 gene, a ROS1 kinase, or the expression or activity or level of any of the same in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (d) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject as a monotherapy or in conjunction with another anticancer agent (e.g., a second ROS1 inhibitor, a second compound of Formula I, an ALK inhibitor, a TRK inhibitor, or a pharmaceutically acceptable salt thereof) or anticancer therapy (e.g., surgery or radiation) if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations.

In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more ROS1 fusion proteins of Table 2 and/or one or more ROS1 kinase protein point mutations, insertions, and/or deletions (e.g., one or more of the point mutations of Table 3 or Table 3a) in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof selected from the group consisting of a compound of Formula I selected from Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations of Table 4; and (d) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject as a monotherapy or in conjunction with another anticancer agent (e.g., a second ROS1 inhibitor, a second compound of Formula I, an ALK inhibitor, a TRK inhibitor, or a pharmaceutically acceptable salt thereof) or anticancer therapy (e.g., surgery or radiation) if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations. In some embodiments, a second ROS1 inhibitor selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib is administered in step (d). In some embodiments, provided herein are methods for treating a ROS1-associated cancer in a subject in need of such treatment, the method comprising (a) detecting one or more of the fusion proteins SLC34A2-ROS1, CD74-ROS1, EZR-ROS1, TPM3-ROS1, or SDC4-ROS1 in a sample from the subject; and (b) administering to the subject a therapeutically effective amount of a compound of Formula I selected Example No. 2, 3, 7, 9, 14, 19, 20, 22, 33-A, 33-B, 35, 36, and 45, or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the methods further comprise (after (b)) (c) determining whether a cancer cell in a sample obtained from the subject has one or more of the ROS1 inhibitor resistance mutations L2026M, G2032R, or D2033N; and (d) administering additional doses of the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof of step (b) to the subject as a monotherapy or in conjunction with another anticancer agent (e.g., a second ROS1 inhibitor, a second compound of Formula I, an ALK inhibitor, a TRK inhibitor, or a pharmaceutically acceptable salt thereof) or anticancer therapy (e.g., surgery or radiation) if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations. In some embodiments, a second ROS1 inhibitor selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesestinib is administered in step (d).

Also provided are methods of selecting a treatment for a subject having a cancer that include: identifying a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations; and selecting a treatment that includes administration of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with a first ROS1 inhibitor. In some embodiments, the compound of Formula I or a pharmaceutically acceptable salt or solvate thereof is administered in combination with the first ROS1 inhibitor. Also provided are methods of selecting a treatment for a subject having a cancer that include: selecting a treatment that includes administration of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof for a subject identified as having a cancer cell that has one or more ROS1 inhibitor resistance mutations. Also provided are methods of selecting a subject having a cancer for a treatment that does not include a first ROS1 inhibitor as a monotherapy that include: identifying a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations; and selecting the identified subject for a treatment that includes a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. Also provided are methods of selecting a subject having a cancer for a treatment that does not include a first ROS1 inhibitor as a monotherapy that include: selecting a subject identified as having a cancer cell that has one or more ROS1 inhibitor resistance mutations for a treatment that includes administration of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. In some embodiments, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N.

Also provided are methods of determining the likelihood that a subject having a cancer (e.g., a ROS1-associated cancer) will have a positive response to treatment with a first ROS1 inhibitor as a monotherapy that include: determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and determining that a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations has a decreased likelihood of having a positive response (i.e. an increased likelihood of having a negative response) to treatment with a first ROS1 inhibitor as a monotherapy. Also provided are methods of determining the likelihood that a subject having a cancer (e.g., a ROS1-associated cancer) will have a positive response to treatment with a first ROS1 inhibitor as a monotherapy that include: determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and determining that a subject not having a cancer cell that has one or more ROS1 inhibitor resistance mutations has an increased likelihood of having a positive response to treatment with a first ROS1 inhibitor as a monotherapy as compared to a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations. Also provided are methods of predicting the efficacy of treatment with a first ROS1 inhibitor as a monotherapy in a subject having cancer that include: determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and determining that treatment with a first ROS1 inhibitor as a monotherapy is less likely to be effective in a subject having a cancer cell in a sample obtained from the subject that has one or more ROS1 inhibitor resistance mutations. Also provided are methods of predicting the efficacy of treatment with a first ROS1 inhibitor as a monotherapy in a subject having cancer that include: determining that treatment with a first ROS1 inhibitor as a monotherapy is less likely to be effective in a subject having a cancer cell in a sample obtained from the subject that has one or more ROS1 inhibitor resistance mutations. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N.

Also provided are methods of treating a subject having a cancer that include: (a) administering a first ROS1 inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (d) administering additional doses of the first ROS1 inhibitor of step (a) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ROS1 inhibitor of step (a), the subject can also be administered another anticancer agent (e.g., a second ROS1 inhibitor, an ALK inhibitor, a TRK inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor (e.g., a second ROS1 inhibitor). In some embodiments of step (c), another anticancer agent can be the first ROS1 inhibitor administered in step (a). In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2032, e.g., L2026M, G2032R, or D2033N.

Also provided are methods of treating a subject having a cancer that include: (a) administering a first ALK inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has one or more ROS1 inhibitor resistance mutations; or (d) administering additional doses of the first ALK inhibitor of step (a) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ALK inhibitor of step (a), the subject can also be administered another anticancer agent (e.g., a second ALK inhibitor, a first ROS1 inhibitor, a TRK inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ALK inhibitor (e.g., a second ALK inhibitor). In some embodiments of step (c), another anticancer agent can be the first ALK inhibitor administered in step (a). In some embodiments of step (c), another anticancer agent can be another ROS1 inhibitor. In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N.

Also provided are methods of treating a subject having a cancer that include: (a) administering a first TRK inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has one or more ROS1 inhibitor resistance mutations; or (d) administering additional doses of the first TRK inhibitor of step (a) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first TRK inhibitor of step (a), the subject can also be administered another anticancer agent (e.g., a second TRK inhibitor, a first ROS1 inhibitor, an ALK inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another TRK inhibitor (e.g., a second TRK inhibitor). In some embodiments of step (c), another anticancer agent can be the first TRK inhibitor administered in step (a). In some embodiments of step (c), another anticancer agent can be another ROS1 inhibitor. In some embodiments, the dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same confers increased resistance to a cancer cell or tumor to treatment with the first TRK inhibitor. In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N.

Also provided are methods of treating a subject having a cancer that include: (a) administering a first ROS1 inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) administering a second ROS1 inhibitor as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (d) administering additional doses of the first ROS1 inhibitor step (a) to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ROS1 inhibitor of step (a), the subject can also be administered another anticancer agent. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof).

Also provided are methods of treating a subject having a cancer (e.g., a ROS1-associated cancer) that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ROS1 inhibitor, has one or more ROS1 inhibitor resistance mutations; and (b) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) administering additional doses of the first ROS1 inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ROS1 inhibitor previously administered to the subject, the subject can also be administered another anticancer agent (e.g., a second ROS1 inhibitor, an ALK inhibitor, a TRK inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor (e.g., a second ROS1 inhibitor). In some embodiments of step (b), another anticancer agent can be the first ROS1 inhibitor administered in step (a).

Also provided are methods of treating a subject having a cancer (e.g., a ROS1-associated cancer) that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ALK inhibitor has one or more ROS1 inhibitor resistance mutations; and (b) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell having one or more ROS1 inhibitor resistance mutations; or (c) administering additional doses of the first ALK inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ALK inhibitor previously administered to the subject, the subject can also be administered another anticancer agent (e.g., a second ALK inhibitor, a TRK inhibitor, a first ROS1 inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiment, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is can be another ALK inhibitor (e.g., a second ALK inhibitor). In some embodiments of step (b), another anticancer agent can be the first ALK inhibitor administered in step (a). In some embodiments of step (b), another anticancer agent can be another ROS1 inhibitor.

Also provided are methods of treating a subject having a cancer (e.g., a ROS1-associated cancer) that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first TRK inhibitor is associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same; and (b) administering a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) administering additional doses of the first TRK inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first TRK inhibitor previously administered to the subject, the subject can also be administered another anticancer agent (e.g., a second TRK inhibitor, an ALK inhibitor, a first ROS1 inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is can be another TRK inhibitor (e.g., a second TRK inhibitor). In some embodiments of step (b), another anticancer agent can be the first TRK inhibitor administered in step (a). In some embodiments of step (b), another anticancer agent can be another ROS1 inhibitor.

Also provided are methods of treating a subject having a cancer that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ROS1 inhibitor has one or more ROS1 inhibitor resistance mutations; and (b) administering a second ROS1 inhibitor as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) administering additional doses of the first ROS1 inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ROS1 inhibitor previously administered to the subject, the subject can also be administered another anticancer agent. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments of (b), another anticancer agent can be the first ROS1 inhibitor administered in step (a).

Also provided are methods of treating a subject having a cancer that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ALK inhibitor has one or more ROS1 inhibitor resistance mutations; and (b) administering a ROS1 inhibitor as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) administering additional doses of the first ALK inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first ALK inhibitor previously administered to the subject, the subject can also be administered another anticancer agent. In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be a ROS1 inhibitor (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments of (b), another anticancer agent can be the first ALK inhibitor administered in step (a).

Also provided are methods of treating a subject having a cancer that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first TRK inhibitor is associated with a dysregulation of a ROS1 gene, a ROS1 kinase, or expression or activity or level of any of the same; and (b) administering a ROS1 inhibitor as a monotherapy or in conjunction with another anticancer agent to the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) administering additional doses of the first TRK inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where the subject is administered additional doses of the first TRK inhibitor previously administered to the subject, the subject can also be administered another anticancer agent. In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be a ROS1 inhibitor (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments of (b), another anticancer agent can be the first TRK inhibitor administered in step (a).

Also provided are methods of selecting a treatment for a subject having a cancer that include (a) administering a first ROS1 inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) selecting a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (d) selecting additional doses of the first ROS1 inhibitor of step (a) for the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, when additional doses of the first ROS1 inhibitor of step (a) are selected for the subject, the method can further include selecting doses of another anticancer agent for the subject. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor (e.g., a second ROS1 inhibitor). In some embodiments of step (c), another ROS1 inhibitor can be the first ROS1 inhibitor administered in step (a).

Also provided are methods of selecting a treatment for a subject having a cancer that include (a) administering a first ALK inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) selecting a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (d) selecting additional doses of the first ALK inhibitor of step (a) for the subject if the subject has a cancer cell that does not have has one or more ROS1 inhibitor resistance mutations. In some embodiments, when additional doses of the first ALK inhibitor of step (a) are selected for the subject, the method can further include selecting doses of another anticancer agent for the subject. In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments of step (c), another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor. In some embodiments of step (c), another anticancer agent is the first ALK inhibitor administered in step (a).

Also provided are methods of selecting a treatment for a subject having a cancer that include (a) administering one or more doses of a first TRK inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) selecting a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (d) selecting additional doses of the first TRK inhibitor of step (a) for the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, when additional doses of the first TRK inhibitor of step (a) are selected for the subject, the method can further include selecting doses of another anticancer agent for the subject. In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments of step (c), another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent can be another ROS1 inhibitor. In some embodiments of step (c), another anticancer agent is the first TRK inhibitor administered in step (a).

Also provided are methods of selecting a treatment for a subject having a cancer that include (a) administering a first ROS1 inhibitor to the subject for a period of time (e.g., 1 month, 2 months, 3 months, 6 months, 9 months, 1 year); (b) after (a), determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and (c) selecting a second ROS1 inhibitor as a monotherapy or in conjunction with another anticancer agent if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (d) selecting additional doses of the first ROS1 inhibitor of step (a) for the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, when additional doses of the first ROS1 inhibitor of step (a) are selected for the subject, the method can further include selecting doses of another anticancer agent for the subject. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is another ROS1 inhibitor (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, another ROS1 can be the first ROS1 inhibitor administered in step (a).

Also provided are methods of selecting a treatment for a subject having a cancer that include (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ROS1 inhibitor has one or more ROS1 inhibitor resistance mutations; (b) selecting a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) selecting additional doses of the first ROS1 inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, when additional doses of the first ROS1 inhibitor previously administered to the subject are selected for the subject, the method can further include selecting doses of another anticancer agent (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof) for the subject. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is another ROS1 inhibitor (e.g., a second ROS1 inhibitor). In some embodiments of step (c), another ROS1 inhibitor can be the first ROS1 inhibitor administered in step (a).

Also provided are methods of selecting a treatment for a subject having a cancer (e.g., a ROS1-associated cancer) that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ALK inhibitor has one or more ROS1 inhibitor resistance mutations; and (b) selecting a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) selecting additional doses of the first ALK inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where additional doses of the first ALK inhibitor previously administered to the subject are selected for the subject, the method can further include selecting doses of another anticancer agent (e.g., a second ALK inhibitor, a TRK inhibitor, a first ROS1 inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is can be another ALK inhibitor (e.g., a second ALK inhibitor). In some embodiments of step (b), another anticancer agent can be the first ALK inhibitor administered in step (a). In some embodiments of step (b), another anticancer agent can be another ROS1 inhibitor.

Also provided are methods of selecting a treatment for a subject having a cancer (e.g., a ROS1-associated cancer) that include: (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first TRK inhibitor has one or more ROS1 inhibitor resistance mutations; and (b) selecting a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) selecting additional doses of the first TRK inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, where additional doses of the first TRK inhibitor previously administered to the subject are selected for the subject, the method can further include selecting doses of another anticancer agent (e.g., a second TRK inhibitor, an ALK inhibitor, a first ROS1 inhibitor, or a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, the ROS1 inhibitor resistance mutation includes one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, a ROS1 inhibitor resistance mutation can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is can be another TRK inhibitor (e.g., a second TRK inhibitor). In some embodiments of step (b), another anticancer agent can be the first TRK inhibitor administered in step (a). In some embodiments of step (b), another anticancer agent can be another ROS1 inhibitor.

Also provided are methods of selecting a treatment for a subject having a cancer that include (a) determining whether a cancer cell in a sample obtained from a subject having a cancer and previously administered a first ROS1 inhibitor has one or more ROS1 inhibitor resistance mutations; (b) selecting a second ROS1 inhibitor as a monotherapy or in conjunction with another anticancer agent for the subject if the subject has a cancer cell that has one or more ROS1 inhibitor resistance mutations; or (c) selecting additional doses of the first ROS1 inhibitor previously administered to the subject if the subject has a cancer cell that does not have one or more ROS1 inhibitor resistance mutations. In some embodiments, when additional doses of the first ROS1 inhibitor previously administered to the subject are selected for the subject, the method can further include selecting doses of another anticancer agent (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof) for the subject. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N. In some embodiments, another anticancer agent is any anticancer agent known in the art. For example, another anticancer agent is another ROS1 inhibitor (e.g., a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof). In some embodiments, another ROS1 can be the first ROS1 inhibitor administered in step (a).

Also provided are methods of determining a subject's risk for developing a cancer that has some resistance to a first ROS1 inhibitor that include: determining whether a cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and identifying a subject having a cell that has one or more ROS1 inhibitor resistance mutations as having an increased likelihood of developing a cancer that has some resistance to the first ROS1 inhibitor. Also provided are methods of determining a subject's risk for developing a cancer that has some resistance to a first ROS1 inhibitor that include: identifying a subject having a cell that has one or more ROS1 inhibitor resistance mutations as having an increased likelihood of developing a cancer that has some resistance to the first ROS1 inhibitor. Also provided are methods of determining the presence of a cancer that has some resistance to a first ROS1 inhibitor that include: determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and determining that the subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations has a cancer that has some resistance to the first ROS1 inhibitor. Also provided are methods of determining the presence of a cancer that has some resistance to a first ROS1 inhibitor in a subject that include: determining that a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations has a cancer that has some resistance to the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations confer increased resistance to a cancer cell or tumor to treatment with the first ROS1 inhibitor. In some embodiments, the one or more ROS1 inhibitor resistance mutations include one or more ROS1 inhibitor resistance mutations listed in Table 4. For example, the one or more ROS1 inhibitor resistance mutations can include a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N.

In some embodiments of any of the methods described herein, a ROS1 inhibitor resistance mutation that confers increased resistance to a cancer cell or tumor to treatment with a first ROS1 inhibitor can be any of the ROS1 inhibitor resistance mutations listed in Table 4 (e.g., a substitution at one or more of amino acid positions 2026, 2032, or 2033, e.g., L2026M, G2032R, or D2033N).

Also provided are methods of determining the likelihood that a subject having a cancer will have a positive response to treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy that include: determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and determining that the subject having the cancer cell that has one or more ROS1 inhibitor resistance mutations has an increased likelihood of having a positive response to treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy. Also provided are methods of determining the likelihood that a subject having cancer will have a positive response to treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy that include: determining that a subject having a cancer cell that has one or more ROS1 inhibitor resistance mutations has an increased likelihood of having a positive response to treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy. Also provided are methods of predicting the efficacy of treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy in a subject having cancer that include: determining whether a cancer cell in a sample obtained from the subject has one or more ROS1 inhibitor resistance mutations; and determining that treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy is likely to be effective in a subject having a cancer cell in a sample obtained from the subject that has one or more ROS1 inhibitor resistance mutations. Also provided are methods of predicting the efficacy of treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy in a subject having cancer that include: determining that treatment with a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof as a monotherapy is likely to be effective in a subject having a cancer cell in a sample obtained from the subject that has one or more ROS1 inhibitor resistance mutations.

Methods of determining the level of resistance of a cancer cell or a tumor to a ROS1 inhibitor (e.g., any of the ROS1 inhibitors described herein or known in the art) can be determined using methods known in the art. For example, the level of resistance of a cancer cell to a ROS1 inhibitor can be assessed by determining the IC₅₀ of a ROS1 inhibitor (e.g., any of the ROS1 inhibitors described herein or known in the art) on the viability of a cancer cell. In other examples, the level of resistance of a cancer cell to a ROS1 inhibitor can be assessed by determining the growth rate of the cancer cell in the presence of a ROS1 inhibitor (e.g., any of the ROS1 inhibitors described herein). In other examples, the level of resistance of a tumor to a ROS1 inhibitor can be assessed by determining the mass or size of one or more tumors in a subject over time during treatment with a ROS1 inhibitor (e.g., any of the ROS1 inhibitors described herein). In other examples, the level of resistance of a cancer cell or a tumor to a ROS1 inhibitor can be indirectly assessed by determining the activity of a ROS1 kinase including one or more of the ROS1 inhibitor resistance mutations (i.e., the same ROS1 kinase expressed in a cancer cell or a tumor in a subject). The level of resistance of a cancer cell or tumor having one or more ROS1 inhibitor resistance mutations to a ROS1 inhibitor is relative to the level of resistance in a cancer cell or tumor that does not have one or more ROS1 inhibitor resistance mutations (e.g., a cancer cell or tumor that does not have the same ROS1 inhibitor resistance mutations, a cancer cell or a tumor that does not have any ROS1 inhibitor resistance mutations, or a cancer cell or a tumor that expresses a wildtype ROS1 protein). For example, the determined level of resistance of a cancer cell or a tumor having one or more ROS1 inhibitor resistance mutations can be greater than about 1%, greater than about 2%, greater than about 3%, greater than about 4%, greater than about 5%, greater than about 6%, greater than about 7%, greater than about 8%, greater than about 9%, greater than about 10%, greater than about 11%, greater than about 12%, greater than about 13%, greater than about 14%, greater than about 15%, greater than about 20%, greater than about 25%, greater than about 30%, greater than about 35%, greater than about 40%, greater than about 45%, greater than about 50%, greater than about 60%, greater than about 70%, greater than about 80%, greater than about 90%, greater than about 100%, greater than about 110%, greater than about 120%, greater than about 130%, greater than about 140%, greater than about 150%, greater than about 160%, greater than about 170%, greater than about 180%, greater than about 190%, greater than about 200%, greater than about 210%, greater than about 220%, greater than about 230%, greater than about 240%, greater than about 250%, greater than about 260%, greater than about 270%, greater than about 280%, greater than about 290%, or greater than about 300% of the level of resistance in a cancer cell or tumor that does not have one or more ROS1 inhibitor resistance mutations (e.g., a cancer cell or tumor that does not have the same ROS1 inhibitor resistance mutations, a cancer cell or a tumor that does not have any ROS1 inhibitor resistance mutations, or a cancer cell or a tumor that expresses a wildtype ROS1 protein).

Also provided is a method for inhibiting ROS1 kinase activity in a cell, comprising contacting the cell with a compound of Formula I. In some embodiments, the contacting is in vitro. In some embodiments, the contacting is in vivo. In some embodiments, the contacting is in vivo, wherein the method comprises administering an effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof to a subject having a cell having ROS1 kinase activity. In some embodiments, the cell is a cancer cell. In some embodiments, the cancer cell is any cancer as described herein. In some embodiments, the cancer cell is a ROS1-associated cancer cell.

Also provided is a method for inhibiting ROS1 kinase activity in a mammalian cell, comprising contacting the cell with a compound of Formula I. In some embodiments, the contacting is in vitro. In some embodiments, the contacting is in vivo. In some embodiments, the contacting is in vivo, wherein the method comprises administering an effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof to a mammal having a cell having ROS1 kinase activity. In some embodiments, the mammalian cell is a mammalian cancer cell. In some embodiments, the mammalian cancer cell is any cancer as described herein. In some embodiments, the mammalian cancer cell is a ROS1-associated cancer cell.

As used herein, the term “contacting” refers to the bringing together of indicated moieties in an in vitro system or an in vivo system. For example, “contacting” a ROS1 kinase with a compound provided herein includes the administration of a compound provided herein to an individual or patient, such as a human, having a ROS1 kinase, as well as, for example, introducing a compound provided herein into a sample containing a cellular or purified preparation containing the ROS1 kinase.

Also provided herein is a method of inhibiting cell proliferation, in vitro or in vivo, the method comprising contacting a cell with an effective amount of a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, or a pharmaceutical composition thereof as defined herein

The phrase “effective amount” means an amount of compound that, when administered to a patient in need of such treatment, is sufficient to (i) treat a ROS1 kinase-associated disease or disorder, (ii) attenuate, ameliorate, or eliminate one or more symptoms of the particular disease, condition, or disorder, or (iii) delay the onset of one or more symptoms of the particular disease, condition, or disorder described herein. The amount of a compound of Formula I that will correspond to such an amount will vary depending upon factors such as the particular compound, disease condition and its severity, the identity (e.g., weight) of the patient in need of treatment, but can nevertheless be routinely determined by one skilled in the art.

When employed as pharmaceuticals, the compounds of Formula I can be administered in the form of pharmaceutical compositions. These compositions can be prepared in a manner well known in the pharmaceutical art, and can be administered by a variety of routes, depending upon whether local or systemic treatment is desired and upon the area to be treated. Administration may be topical (including transdermal, epidermal, ophthalmic and to mucous membranes including intranasal, vaginal and rectal delivery), pulmonary (e.g., by inhalation or insufflation of powders or aerosols, including by nebulizer; intratracheal or intranasal), oral or parenteral. Oral administration can include a dosage form formulated for once-daily or twice-daily (BID) administration. Parenteral administration includes intravenous, intraarterial, subcutaneous, intraperitoneal intramuscular or injection or infusion; or intracranial, e.g., intrathecal or intraventricular, administration. Parenteral administration can be in the form of a single bolus dose, or may be, for example, by a continuous perfusion pump. Pharmaceutical compositions and formulations for topical administration may include transdermal patches, ointments, lotions, creams, gels, drops, suppositories, sprays, liquids and powders. Conventional pharmaceutical carriers, aqueous, powder or oily bases, thickeners and the like may be necessary or desirable

Also provided herein are pharmaceutical compositions which contain, as the active ingredient, a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof, in combination with one or more pharmaceutically acceptable carriers (excipients). In some embodiments, the composition is suitable for topical administration. In making the compositions provided herein, the active ingredient is typically mixed with an excipient, diluted by an excipient or enclosed within such a carrier in the form of, for example, a capsule, sachet, paper, or other container. When the excipient serves as a diluent, it can be a solid, semi-solid, or liquid material, which acts as a vehicle, carrier or medium for the active ingredient. Thus, the compositions can be in the form of tablets, pills, powders, lozenges, sachets, cachets, elixirs, suspensions, emulsions, solutions, syrups, aerosols (as a solid or in a liquid medium), ointments containing, for example, up to 10% by weight of the active compound, soft and hard gelatin capsules, suppositories, sterile injectable solutions, and sterile packaged powders. In some embodiments, the composition is formulated for oral administration. In some embodiments, the composition is formulated as a tablet or capsule.

The compositions comprising a compound of Formula I or a pharmaceutically acceptable salt or solvate thereof can be formulated in a unit dosage form, each dosage containing from about 5 to about 1,000 mg (1 g), more usually about 100 mg to about 500 mg, of the active ingredient. The term “unit dosage form” refers to physically discrete units suitable as unitary dosages for human subjects and other patients, each unit containing a predetermined quantity of active material (i.e., a compound for Formula I as provided herein) calculated to produce the desired therapeutic effect, in association with a suitable pharmaceutical excipient.

In some embodiments, the compositions provided herein contain from about 5 mg to about 50 mg of the active ingredient. One having ordinary skill in the art will appreciate that this embodies compounds or compositions containing about 5 mg to about 10 mg, about 10 mg to about 15 mg, about 15 mg to about 20 mg, about 20 mg to about 25 mg, about 25 mg to about 30 mg, about 30 mg to about 35 mg, about 35 mg to about 40 mg, about 40 mg to about 45 mg, or about 45 mg to about 50 mg of the active ingredient.

In some embodiments, the compositions provided herein contain from about 50 mg to about 500 mg of the active ingredient. One having ordinary skill in the art will appreciate that this embodies compounds or compositions containing about 50 mg to about 100 mg, about 100 mg to about 150 mg, about 150 mg to about 200 mg, about 200 mg to about 250 mg, about 250 mg to about 300 mg, about 350 mg to about 400 mg, or about 450 mg to about 500 mg of the active ingredient.

In some embodiments, the compositions provided herein contain from about 500 mg to about 1,000 mg of the active ingredient. One having ordinary skill in the art will appreciate that this embodies compounds or compositions containing about 500 mg to about 550 mg, about 550 mg to about 600 mg, about 600 mg to about 650 mg, about 650 mg to about 700 mg, about 700 mg to about 750 mg, about 750 mg to about 800 mg, about 800 mg to about 850 mg, about 850 mg to about 900 mg, about 900 mg to about 950 mg, or about 950 mg to about 1,000 mg of the active ingredient.

The active compound may be effective over a wide dosage range and is generally administered in a pharmaceutically effective amount. It will be understood, however, that the amount of the compound actually administered will usually be determined by a physician, according to the relevant circumstances, including the condition to be treated, the chosen route of administration, the actual compound administered, the age, weight, and response of the individual patient, the severity of the patient's symptoms, and the like.

Provided herein are pharmaceutical kits useful, for example, in the treatment of RET-associated diseases or disorders, such as cancer or irritable bowel syndrome (IBS), which include one or more containers containing a pharmaceutical composition comprising a therapeutically effective amount of a compound provided herein. Such kits can further include, if desired, one or more of various conventional pharmaceutical kit components, such as, for example, containers with one or more pharmaceutically acceptable carriers, additional containers, etc., as will be readily apparent to those skilled in the art. Instructions, either as inserts or as labels, indicating quantities of the components to be administered, guidelines for administration, and/or guidelines for mixing the components, can also be included in the kit.

One skilled in the art will recognize that, both in vivo and in vitro trials using suitable, known and generally accepted cell and/or animal models are predictive of the ability of a test compound to treat or prevent a given disorder.

One skilled in the art will further recognize that human clinical trials including first-in-human, dose ranging and efficacy trials, in healthy patients and/or those suffering from a given disorder, may be completed according to methods well known in the clinical and medical arts.

EXAMPLES Example A. Inhibition of ROS1 Kinase

The potency of a compound inhibiting wild type and exemplary mutant ROS1 kinases was determined using CisBio's HTRF Kinease-TK assay technology. The assays contained 5 nM wild type ROS1 (SignalChem—Cat. No. R14-11G), 5 nM G2032R ROS1 (SignalChem—Cat. No. R14-12BG), 5 nM L2026M ROS1 (Array Biopharma, p1965), or 5 nM D2033N ROS1 (Array Biopharma, p1994). Each kinase is incubated with 250 nM TK-substrate biotin (CisBio, Cat. No. 62TK0PEC) and 1 mM ATP along with test compound in a buffer consisting of 25 mM MOPS [pH 7.4], 5 mM MgCl₂, 0.005% Triton X-100, and 2% DMSO in a volume of 8 μL. Compounds were prepared in a four-fold serial dilution in DMSO and added to the assay to give the appropriate final concentration. After a 120-minute incubation at 22° C., the reaction was quenched by adding 8 μL of quench solution containing 31.3 nM Sa-XL665 and 1× TK-Ab-Cryptate in HTRF detection buffer (CisBio, Cat. No. 62TK0PEC). After a 1 hour incubation at 22° C., the extent of reaction was determined using a PerkinElmer EnVision multimode plate reader via HTRF dual wavelength detection, and the percent of control (POC) was calculated using a ratiometric emission factor. 100 POC is determined using no test compound and 0 POC is determined in the absence of enzyme. The POC values are fit to a 4-parameter logistic curve and the IC₅₀ value is calculated based on the point at which the curve crosses 50 POC.

Table 9 provides averaged IC₅₀ values for compounds tested in this assay.

TABLE 9 ROS1 ROS1 ROS1 ROS1 Compound wT G2032R L2026M D2033N No. Structure IC₅₀ (nM) IC₅₀ (nM) IC₅₀ (nM) IC₅₀ (nM)  2

80.3 1062.2 67.0 11.9  3

1.2 9.4 1.2 0.3  7

3.1 29.2 2.9 0.6  9

9.2 98.6 10.2 1.7 14

28.9 107.3 30.3 7.6 19

2.4 14.4 2.4 1.2 20

2.5 21.6 2.2 2.8 22

330.6 3980.2 712.9 396.9 33-A

19.2 157.1 19.6 14.3 33-B

2.7 20.4 3.6 0.5 35

779.1 4931.9 589.3 260.1 36

0.7 6.5 0.5 0.2 45

6.1 113.6 4.6 16.8

OTHER EMBODIMENTS

It is to be understood that while the disclosure has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the disclosure, which is defined by the scope of the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims. 

What is claimed is:
 1. A method for treating a ROS1-associated cancer in a subject in need thereof, wherein the cancer has developed resistance to a first ROS1 inhibitor, and wherein the cancer has been identified as having one or more ROS1 inhibitor resistance mutations, the method comprising administering (6R,15R)-9-fluoro-15-methyl-2,11,16,20,21,24-hexaazapentacyclo[16.5.2.0^(2,6).0^(7,12).0^(21,25)]pentacosa-1(24),7,9,11,18(25),19,22-heptaen-17-one; or a pharmaceutically acceptable salt thereof.
 2. The method of claim 1, wherein the first ROS1 inhibitor is selected from the group consisting of alectinib, brigatinib, cabozantinib, ceritinib, crizotinib, entrectinib, foretinib, lorlatinib, and mesetinib.
 3. The method of claim 2, wherein the first ROS1 inhibitor is alectinib.
 4. The method of claim 2, wherein the first ROS1 inhibitor is brigatinib.
 5. The method of claim 2, wherein the first ROS1 inhibitor is cabozantinib.
 6. The method of claim 2, wherein the first ROS1 inhibitor is ceritinib.
 7. The method of claim 2, wherein the first ROS1 inhibitor is crizotinib.
 8. The method of claim 2, wherein the first ROS1 inhibitor is entrectinib.
 9. The method of claim 2, wherein the first ROS1 inhibitor is lorlatinib.
 10. The method of claim 2, wherein the first ROS1 inhibitor is mesetinib.
 11. The method of claim 1, wherein the one or more ROS1 inhibitor resistance mutations comprise one or more amino acid substitutions at an amino acid position selected from 1186, 1935, 1945, 1946, 1947, 1948, 1951, 1958, 1959, 1961, 1962, 1971, 1974, 1981, 1982, 1986, 1990, 1993, 1994, 2000, 2002, 2004, 2008, 2009, 2010, 2011, 2016, 2019, 2020, 2022, 2026, 2028, 2029, 2030, 2032, 2033, 2035, 2036, 2039, 2040, 2052, 2059, 2060, 2075, 2077, 2078, 2087, 2091, 2092, 2094, 2098, 2099, 2100, 2101, 2106, 2107, 2112, 2113, 2116, 2125, 2127, 2128, 2131, 2134, 2139, 2141, 2142, 2148, 2151, 2154, 2155, 2160, 2165, 2181, 2184, 2201, 2205, 2207, 2209, 2212, and
 2224. 12. The method of claim 1, wherein the one or more ROS1 inhibitor resistance mutations comprise one or more amino acid substitutions selected from S1186F, E1935G6, L1945Q, T1946S, L1947R, L1947M, R1948S, L1951R, L1951V, E1958V, V1959E, E1961K, G1962E, G1971E, E1974K, T1981M, L1982F, L1982R, 51986Y, 51986F, E1990G, E1990L, E1993K, F1994L, L2000V, 52002N, F2004L, F20041, F2004V, F2004C, N2008H, 12009L, L2010M, K2011N, C2016G, N2019D, N2019Y, E2020K, Q2022H, L2026M, L2028M, M2029K, E2030K, G2032R, D2033G, D2033N, L20351, T20361, T2036N, R2039G, R2039H, R2039M, R2039N, R2039S, K2040E, K2040Q, T2052S, L2059P, C2060G, F2075C, F20751, F2075V, H2077P, R2078W, V20871, D2091N, Y2092N, 52094N, V20981, K2099N, 12100V, G2101A, A2106P, R2107T, N2112K, D2113N, D2113G, R2116T, R2116K, V2125G, V2125L, W2127G, M2128T, E2131D, E2131K, M2134I, T2139I, T2139S, Q2141H, 52142Y, G2148E, I2151N, I2154M, L2155S, Q2160H, H2165D, E2181D, R2184T, E2201D, R2205I, T2207I, H2209P, Q2212H, Q2212P, and N2224K.
 13. The method of claim 1, wherein the one or more ROS1 inhibitor resistance mutations comprise one or more amino acid substitutions at an amino acid position selected from 2026, 2032, and
 2033. 14. The method of claim 13, wherein the one or more ROS1 inhibitor resistance mutations comprise one or more amino acid substitutions selected from L2026M, G2032R, and D2033N.
 15. The method of claim 1, wherein the ROS1-associated cancer is selected from the group consisting of: lung cancer, colorectal cancer, gastric cancer, adenocarcinoma, small bowel adenocarcinoma, cholangiocarcinoma, glioblastoma, ovarian cancer, angiocarcinoma, congenital gliobastoma multiforme, papillary thyroid carcinoma, inflammatory myofibroblastic tumour, a spitzoid neoplasm, anaplastic large cell lymphoma, diffuse large B cell lymphoma, and B-cell acute lymphoblastic leukemia. 